LIBRARY 

OF    THE 

4 

UNIVERSITY  OF  CALIFORNIA. 


SURGICAL  AND  OBSTETRICAL 
OPERATIONS 


FOR 


Veterinary  Students  and  Practitioners 


BY 


W.  L.  WILLIAMS 

»-  • 

Professor  of  Obstetrics  and  Surgery  in  the  New  York  State  Veterinary 
College,  Cornell  University. 


Embodying  portions  of  the  OPERATIONSKURSUS  of  Dr.  W.  Pfeiffer, 
Professor  of  Veterinary  Science  in  the  University  of  Giessen. 


PUBLISHED  BY  THE  AUTHOR 
ITHACA,  N.  Y, 


' 


^. 


i 


COPYRIGHT,   1903,  BY 
W.  I,.  WIHIAMS. 


PRESS  OF 

ANDRUS   &    CHUKCH 
ITHACA,   N.   Y. 


PREFACE. 

The  author  caused  to  be  published  in  1900  a  booklet 
entitled:  "  A  Course  in  Surgical  Operations  by  W.  PfeifTer 
and  W.  L.  Williams,  "  consisting  of  an  authorized  transla- 
tion of  Dr.  Pfeiffer's  Operation s-Cursus  with  such  changes, 
omissions  and  additions  as  were  deemed  desirable.  Three 
years  of  constant  use,  with  such  criticisms  as  have  come  to 
the  author  from  others,  have  served  to  point  out  desirable 
changes  of  so  sweeping  a  character  as  to  demand  a  practi- 
cally new  treatise  and  to  render  the  continuance  of  a  formal 
joint  authorship  inexpedient.  The  author  has  drawn  freely 
upon  Dr.  Pfeiffer's  Operations- Cursus  in  the  preparation  of 
the  text  which  in  many  chapters  is  practically  copied  there- 
from, including  the  illustrations,  and  gratefully  acknowl- 
edges his  profound  obligations  thereto.  On  the  other  hand 
nothing  has  been  copied  or  extracted  except  it  could  be  freely 
adopted  as  the  author's  own  view,  releasing  Dr.  Pfeiffer 
from  all  responsibility  for  the  character  of  any  of  the  con- 
tents. 

The  volume  is  primarily  designed  for  the  use  of  the  auth- 
or's classes  in  laboratory  surgery  and  embryotomy  in  which 
the  student  performs  the  surgical  operations  described,  on 
animals  procured  for  the  express  purpose,  under  chloroform 
anaesthesia  whenever  possible,  after  which  the  subject  is 
destroyed  while  still  anaesthetized  ;  at  the  same  time  it  has 
been  aimed  to  render  the  volume  of  the  greatest  possible 
value  to  the  practitioner  consistent  with  this  plan.  The 
operations  included  under  this  scheme  are  necessarily  limited 
to  those  which  can  be  reasonably  well  performed  on  com- 
paratively sound  animals  of  little  value  and  regularly  pro- 
curable for  laboratory  purposes.  The  list  covers  a  wide 
range  and  is  designed  to  give  to  the  student  as  thorough 
training  as  is  practicable  in  a  laboratory  course  and  includes 
well  nigh  all  the  more  important  varieties  of  confinement, 
anaesthesia,  disinfection,  sutures,  bandaging,  dressing  and 
other  adjuncts  to  operative  work.  The  chapter  on  trephin- 

127691 


iv  PREFACE. 

ing  of  the  facial  sinuses  has  been  dealt  with  at  length  in 
order  to  fully  and  clearly  describe  the  author's  method  of 
operating  ;  a  new  operation  for  poll  evil  has  been  inserted 
and  there  has  been  included  a  description  of  some  of  the 
most  important  embryotomy  operations  as  they  are  carried 
out  in  the  laborator}'  by  means  of  freshly  killed,  new. born 
calves  which  are  placed  in  the  position  desired,  in  the  arti- 
ficial uterus  of  a  specially  prepared  skeleton. 

Generally  but  one  method  of  operating  is  described,  the 
one  chosen  being  that  which  in  the  author's  experience  has 
proven  the  most  valuable  in  actual  practice,  and  no  opera- 
tion has  been  introduced  purely  for  practice  but  each  one 
has  been  tested  and  known  to  have  practical  value. 

Where  two  methods  of  operating  are  given,  they  are 
inserted  because  each  has  definite  points  of  superiority  over 
the  other  and  one  method  may  be  specially  applicable  in  a 
given  case,  another  in  a  different  patient  where  the  same 
operation  is  to  be  performed  as  for  example,  a  milk  cow  is 
best  spayed  tjirough  the  vagina  while  a  heifer  must  be 
operated  on  by  an  incision  through  the  abdominal  walls. 

Considerable  stress  has  been  laid  upon  the  surgical  an- 
atomy of  the  parts  involved  in  each  operation  ;  some  uses  of 
the  various  operations  are  mentioned  ;  some  of  the  chief 
dangers  of  each  are  pointed  out  and  in  some  cases  references 
to  literature  upon  the  operation  or  the  diseases  for  which  the 
operation  is  designed,  are  cited. 

The  figures  in  the  text  except  Nos.  5,  10  and  n,  and  the 
Plates  Nos.  I,  II,  VIII,  X,  XII,  XIV,  XVII,  XVIII, 
XXI,  XXII,  XXIII,  XXV,  XXVIII  and  XXIX  are  from 
Dr.  Pfeiffer's  Operations-Cursus  ;  Plate  No.  Ill  was  drawn 
by  Dr.  C.  F.  Flocken,  Bureau  of  Animal  Industry,  Wash- 
ington, D.  C.,  and  the  remaining  Plates  were  drawn  tinder 
the  direction  of  the  author  by  Mr.  C.  W.  Furlong,  In- 
structor in  Industrial  Drawing  and  Art  in  Sibley  College, 

Cornell  University. 

W.  L,.  WILLIAMS. 
Cornell  University,  October,  1903. 


CONTENTS. 

I. 

I.   OPERATIONS  ON  THE  HEAD  : 

Page. 

*"  i.  Extraction  of  Teeth I 

^  2.  Repulsion  of  Teeth n 

Trephining  the  Facial  Sinuses 18 

"3.  Trephining  of  the  Frontal  Sinuses 21 

4.  Trephining  the  Maxillary  Sinuses 33 

5.  Trephining  the  Nasal  Fossae 36 

L)  6.  Poll  Evil  Operation 37 

>  7.  Ligation  of  the  Parotid  Duct.  _fc 41 

8.  Entropium  Operation 1 46 

9.  Staphylotoniy Y 47 

?  10.  Trifacial  Neurotomy fi 48 

II.    OPERATIONS  ON  THE  NECK  : 

ii.  Opening  the  Guttural  Pouches 53 

J2  12.  Tracheotomy V?.. 59 

-  13.  Arytenectomy \*?- 61 

14.  Intra:tracheal  Irrigation ¥- 66 

^15.  Intravenous  Injection jS. 67 

/  16.  a.  Phlebotomy  with  Fleams 69 

b.  Phlebotomy  with  Lancet 70 

c.  Phlebotomy  with  Trocar 71 

17.  Ligation  of  the  Carotid  Artery__  .\/. 71 

1 8.  CEsophagotomy 76 

III.     OPERATIONS  ON  THE  TRUNK  AND  ON  THE  GENITAI,  ORGANS  \ 

Lfig.  Puncture  of  the  Chest 78 

ij2o.  Puncture  of  the  Intestine 79 

y2i.  Subcutaneous  Caudal  My otomy <Si 

^"22.  Caudal  Myectomy  for  Gripping  of  the  Reins  __K 83 

23.  Amputation  of  the  Tail 

524.  Urethrotomy 9° 

25.  Amputation  of  the  Penis 93 

^'26.  Vaginal  Ovariotomy  in  the  Mare 97 

27.  Vaginal  Ovariotomy  in  the  Cow 1^___     107 

28.  Ovariotomy  in  the  Cow  by  the  Flank ^1 109 


vi  CONTENTS. 

29.  Ovariotomy  in  the  Bitch  by  the  Flank  __K_ no 

30.  Ovariotomy  in  the  Bitch  by  the  Linea  Alba 117 

31.  Ovariotomy  in  the  Cat J<__ 118 

IV.     OPERATIONS   ON   THE   EXTREMITIES  : 

>•  32.  Tenotomy  of  the  Flexor  Tendons  of  the  Foot  __bf_ 119 

33.  Tenotomy  of  the  Pei oneal  Tendon  (Stringhalt  Operation ).__  121 

-"I  34.  Tenotomy  of  the  Cunean  Tendon   (Spavin  Operation) 125 

Neurotomy 129 

/35-  Digital  Neurotomy 132 

736.  Plantar  Neurotomy_7_$*--±_^- 137 

jk,37-  Median  Neurotomy 141 

£  38.  Dinar  Neurotomy 147 

$39.  Sciatic  Neurotomy  V^ 153 

40.  Anterior  Tibial  Neurotomy 163 

41.  Resection  of  the  Lateral  Cartilages W 165 

;  y  42.  Resection  of  the  Flexor  Pedis  Tendon J/IL 172 

43.  Amputation  of  the  Claws  of  Ruminants V- J74 

44.  Bayer's  Sutures 179 

II. 
EMBRYOTOMY  OPERATIONS  : 

45.  Cephalotomy  _.J^ 183 

46.  Decapitation  ___J/ 185 

47.  Subcutaneous  Amputation  of  Anterior  Limb  y/_ 185 

48.  Amputation  at  the  Humero-radial  Articulation  __^ 187 

49.  Detruncation yt 188 

50.  Destruction  of  the  Pelvic  Girdle,  Anterior  Presentation _^_ __  192 

51.  Amputation  of  the  Limbs  at  the  Tarsus ^ 196 

52.  Intra-pelvic  Amputation  of  the  Posterior  Limbs,  Breech  Pre- 

sentation __V_ 200 

53.  Evisceration  of  the  Fetus  __i^ 209 


INTRODUCTION. 

Many  details  must  be  omitted  in  the  succeeding  text  which 
are  of  importance  in  each  operation,  but  which,  if  inserted, 
would  render  the  volume  unwieldy  in  size  for  the  purpose 
designed. 

These  details  are  in  a  measure  alike  in  each  case,  and  it  is 
assumed  that  the  student  has  already  familiarized  himself 
with  them.  The  more  important  of  these  may  be  summa- 
rized as  follows  : 

1.  The  subject  should  bo  securely   confined    in  each  case 
as  directed,  because  the  method  designated  has  been  found 
effective  in  the  operation  under  description,  and  serves  to  fix 
the  relations  of  the  parts  in  such  a  way  as  to  conform  to  the 
surgical  anatomy  of  the  region   as  outlined  in  the  text.      It 
is  to  be  constantly  borne   in   mind   that  a  change  in  the  atti- 
tude of  the  animal  is  capable  of  causing  profound  alterations 
in  the   relations  of  parts  which   may   greatly   embarass  the 
operator,   or  even   prevent   his  carrying    out  the    operation 
according  to  the  technic  given.      In  securing  an  animal  for 
operation  we  must  confine  the  whole  body  in  a  way  that  will 
sufficiently  control  movements  and  will  insure  safety  to  the 
patient  and  operator  ;  the  part  to  be  operated  upon  must  be 
so  fixed  as  to  properly  limit   its  motion  and  in  a  position  to 
afford  the  greatest  facility  for  the  carrying  out  of  the  opera- 
tion according  to  the  best  technic  known. 

2.  Anaesthesia  should  be  carefully  carried  out  everywhere 
possible,  because  in   addition   to  the  humane  sentiments  in- 
volved,   the   resulting   perfect  control   of  the  animal    is  an 
essential    in    aseptic    or    antiseptic    surgery.     The    student 
should  make  a  careful  study  of  anaesthesia  in  these  exercises 
and  acquire  invaluable  experience  and  confidence  for  use  in 
actual  practice. 

3.  Disinfection  must  be  scrupulously  applied  in  every  de- 
tail since    upon   its   effectiveness  must   hang   the   verdict  of 


vm  INTRODUCTION. 

success  or  failure  as  measured  by  modern  surgical  knowl- 
edge. The  operator's  hands  and,  if  need  be,  his  arms 
should  be  thoroughly  scrubbed  with  a  stiff  brush  in  hot 
water  with  soap  for  a  period  of  fifteen  minutes,  the  finger 
nails  well  trimmed  and  cleansed,  and  all  dirt  and  old  epider- 
mal scales  removed.  The  parts  may  then  be  disinfected  by 
immersing  in  a  hot  concentrated  solution  of  permanganate 
of  potassium  for  ten  minutes  and  then  decolorized  in  a  strong 
solution  of  oxalic  acid  in  sterile  water.  Or  the  hands  may 
be  disinfected  after  the  washing  with  soap  and  water  by  im- 
mersing and  scrubbing  them  for  ten  minutes  in  a  i  to  1000 
solution  of  corrosive  sublimate,  but  in  order  to  make  this 
thoroughly  effective  the  solution  needs  be  alcoholic,  or  the 
hands  should  first  be  immersed  in  alcohol,  ether,  or  other 
substance  capable  of  dissolving  fats  and  permitting  the  dis- 
infectant to  penetrate  the  sebaceous  glands.  Great  care 
should  be  exercised  by  the  student  to  not  touch  any  object 
after  the  hands  have  been  disinfected  for  the  operation  unless 
it  has  been  disinfected  or  sterilized,  or  in  case  it  becomes 
necessary  to  touch  objects  not  sterile,  the  disinfecting  process 
should  be  repeated  before  proceeding  further  with  the  oper- 
ation. This  constitutes  one  of  the  most  difficult  of  all  details 
for  the  beginner  to  acquire,  and  each  failure  should  be 
remedied  by  repeating  the  disinfection  over  and  over  until 
the  habit  of  maintaining  effectual  sterilization  is  acquired 
and  fixed. 

The  operation  field  should  always  be  carefully  shaved  be- 
fore beginning  the  operation,  and  the  shaved  area  should 
always  be  very  ample,  so  as  to  insure  against  contamination 
from  adjacent  hairs,  as  well  as  to  give  a  clear  view  of  the 
field.  The  area  should  then  be  disinfected  in  a  reliable 
manner,  that  advised  for  the  operator's  hands  serving  as  a 
type.  Whenever  circumstances  will  permit  the  operation 
field  should  be  kept  in  an  antiseptic  bath  or  pack  for  twenty- 
four  hours  prior  to  the  operation  in  order  that  the  deeper 
parts  of  the  skin,  especially  the  hair  follicles  and  sebaceous 


INTRODUCTION.  IX 

glands,  shall  become  thoroughly  disinfected,  a  process  well 
nigh  impossible  in  a  short  period. 

The  suturing,  dressing  and  bandaging  of  the  wound 
should  be  carried  out  carefully  in  every  case  and  no  opera- 
tion left  without  completing  it  in  the  best  manner  possible. 

The  student  should  make  each  operation  as  real  as  possible 
and  not  omit  any  detail  even  if  he  thinks  he  already  knows 
it  sufficiently  well  as  the  repetition  of  a  supposedly  familiar 
detail  serves  an  important  purpose  in  the  fixing  of  a  habit 
which  is  inestimably  more  valuable  to  the  surgeon  than  any 
theoretical  knowledge  of  technic. 

The  safe  surgeon  is  he  who  has  .so  accustomed  himself  to 
the  technique  of  asepsis  and  antisepsis  that  he  carries  them 
out  rigidly  in  an  automatic  manner  and  can  leave  his  atten- 
tion riveted  on  the  surgical  problems  before  him. 

The  student 'who  consults  his  interests  will  go  yet  farther 
and  prior  to  undertaking  any  operation  on  the  living  subject 
will  study  the  regional  anatomy  of  the  part  on  the  cadaver 
and  learn  therefrom  all  that  he  can  of  the  structure  of  the 
part  which  he  must  finally  complete  upon  the  living  animal. 
No  dissection  of  the  cadaver  can  ever  teach  true  surgical 
structure  as  the  dead  tissues  can  not  be  like  the  living,  but 
such  dissection  can  and  does  give  great  aid  and  should 
be  pursued  as  far  as  it  can  lead  and  enough  will  still  remain 
to  be  learned  on  the  living  subject. 

He  should  further  take  occasion  to  study,  in  connection 
with  each  operation  the  object  or  objects  for  which  it  is  per- 
formed in  practice,  its  effect  on  the  diseased  or  other  parts, 
the  untoward  results  to  be  anticipated,  etc. 

Suggestions  occur  from  time  to  time  in  the  text  designed 
to  aid  the  student  in  these  lines  and  help  weave  connecting 
bands  between  the  operation,  its  objects  and  results. 

Surgical  operations  are  in  themselves  valueless  or  worse 
and  acquire  value  only  when  properly  correlated  to  disease 
and  skillfully  performed. 


, 

Surgical  and  Obstetrical  Operations. 


I.  SURGICAL  OPERATIONS. 


OPERATIONS  ON  THE  HEAD. 

i.  EXTRACTION  OF  TEETH. 

PIRATES  I  AND  II. 

Prefatory  remarks.  The  grinding  teeth  of  the  horse 
consisting  of  three  molars  and  three  premolars  in  each  row 
are  of  such  dimensions  and  attachments  that  their  removal 
in  case  of  disease  or  defect  often  presents  difficulties  of  no 
small  degree. 

These  teeth  attain  their  greatest  size  at  the  time  of  erup- 
tion and  most  of  the  tooth  remains  firmly  imbedded  in  its 
alveolus  while  a  very  shallow  crown  projects  into  the  buccal 
cavity.  The  teeth  are  gradually  pushed  out  of  their  alveoli 
as  their  crowns  are  worn  away  with  age  and  the  proportion 
of  the  intra-  to  the  extra-alveolar  part  gradually  decreases 
until  in  very  old  animals  the  alveoli  become  obliterated  and 
the  last  vestige  of  what  was  once  the  apex  of  the  fang  rests 
insecurely  in  the  buccal  mucous  membrane. 

The  facility  with  which  teeth  may  be  extracted  increases 
as  the  age  of  the  animal  increases,  being  easily  drawn  with 
forceps  in  the  old,  while  in  case  of  freshly  erupted  teeth  in 
the  young  horse  we  have  not  been  able  to  extract  them  with 
forceps  of  any  kind,  except  in  those  cases  where  they  have 
become  somewhat  loosened  as  a  result  of  disease  or  accident. 
When  aberrations  in  development  occur,  leading  to  the  for- 
mation of  dental  tumors  or  odontomes  the  possibilit}7  of  ex- 
traction by  means  of  forceps  is  frequently  wholly  excluded 
and  in  cases  where  dental  disorder  has  led  to  empyema  of 
the  facial  sinuses,  even  if  the  tooth  may  be  drawn  by  means 
of  forceps,  further  operation  is  generally  necessary,  in  order 


2  EXTRACTION  OF  TEETH. 

to  assure  a  prompt  recovery,  by  the  removal  of  the  effects 
of  the  disease  of  the  tooth. 

The  removal  of  molars  may  therefore  involve  extraction 
with  forceps,  trephining  the  dental  alveolus  and  repulsion 
of  the  tooth  and  trephining  of  the  sinuses  because  of  em- 
pyema  or  other  pathologic  conditions  referable  to  the  dental 
affection  ;  consequently  all  of  these  should  be  studied  as  re- 
lated topics. 

Instruments.  Extracting  forceps,  fulcra  of  various 
sizes,  mouth  speculum  with  abundant  lateral  working  room, 
exporteur  forceps,  toothpick,  splinter  forceps,  reflecting  lamp. 

Technic.  In  simple  cases  with  a  quiet  animal  the  pa- 
tient may  be  sufficiently  confined  by  being  backed  into  a 
corner  or  very  much  better  by  securing  in  stocks.  In  com- 
plicated cases  or  very  resistant  animals  it  is  best  to  place 
upon  the  operating  table  or  in  default  of  this,  cast  and  secure 
in  lateral  decubitis  on  the  opposite  side  to  the  affected  tooth. 

Apply  the  speculum  and  identify  the  diseased  tooth  by 
manual  exploration  ;  determine  if  the  tooth  is  of  unnatural 
size  or  form,  if  it  is  loose,  if  the  gums  are  separated  from  the 
neck  at  any  point,  if  it  is  out  of  line  with  the  other  teeth  in 
the  row,  if  it  is  painful  to  the  touch,  if  it  be  split,  etc.  An 
external  tooth  fistula  or  a  tumefaction  over  the  affected 
member  may  aid  in  distinguishing  it.  Aid  may  also  be  had 
by  illuminating  the  mouth  with  a  reflecting  electric  or  other 
lamp. 

Remove  any  accumulations  of  partially  masticated  food  by 
means  of  the  toothpick  or  with  the  fingers. 

For  extracting  molars  use  forceps  acting  as  a  lever  of  the 
first  class-,  with  a  fulcrum  having  a  plane  and  a  convex  sur- 
face ;  for  the  premolars  use  forceps  acting  as  a  lever  of  the 
second  class.  In  case  of  the  superior  premolars  some  prefer 
forceps  bent  on  the  flat  as  shown  in  Plate  II,  because  if 
straight  the  forceps  handles  strike  against  the  superior  in- 
cisors and  hinder  the  deep  fixation  of  the  forceps  jaws  upon 
the  tooth  crown. 


EXTRACTION  OF  TEETH.  3 

In  applying  the  forceps  to  the  tooth  have  an  assistant  draw 
the  tongue  well  out  at  the  commissure  of  the  lips  on  the  side 
opposite  to  the  affected  member  and  introducing  one  hand 
into  the  mouth,  place  the  index  finger  on  the  posterior 
border  of  the  diseased  tooth  and  with  the  other  hand  push 
the  opened  forceps  backwards  upon  the  tooth  row  until  they 
reach  the  finger,  then  firmly  grasp  the  affected  tooth  with 
the  instrument,  pressing  the  jaws  down  as  deeply  as  possible 
against  the  alveolus.  In  many  cases  the  diseased  tooth  can 
be  clearly  seen  especially  with  the  aid  of  the  reflecting  lamp 
and  the  forceps  readily  applied  with  visual  aid  and  is  fre- 
quently preferable  to  the  guide  of  touch.  Withdraw  the 
free  hand  from  the.  mouth,  grasp  the  handles  with  both 
hands  and  loosen  the  tooth  in  its  alveolus  by  establishing 
and  maintaining  as  long  as  necessary  a  gentle  to  and  fro 
lateral  movement.  The  tooth  is  thus  loosened  in  its  alveolus 
by  causing  it  to  revolve  very  slightly  back  and  forth  on  its 
long  axis.  When  the  tooth  has  become  well  loosened,  as 
indicated  by  its  moving  with  the  forceps  and  by  the  audible 
crackling  sound  caused  by  the  passage  of  air  bubbles  to  and 
fro  through  the  blood  and  lymph  in  the  alveolus  ;  maintain 
the  forceps  in  position  with  one  hand  and  with  the  other 
introduce  the  fulcrum  as  far  back  as  possible  in  the  case  of 
molars  and  place  it  with  the  plane  surface  resting  upon  the 
crowns  of  the  teeth  as  shown  in  Plate  I.  The  fulcrum 
needs  be  held  firmly  in  place  in  order  to  prevent  it  from 
gliding  forward  under  pressure. 

The  tooth  fang  is  extracted  by  forcing  the  handles  of 
the  forceps  toward  the  jaw  in  which  it  is  located,  so  that 
as  it  is  gradually  drawn  out  the  forceps  tend  to  glide  over 
the  convex  surface  of  the  fulcrum  in  a  way  to  permit  the 
tooth  to  emerge  from  the  alveolus  in  the  direction  of  the 
long  axis  of  the  latter.  By  referring  to  Plate  III  it  will  be 
seen  that  the  axes  of  the  different  teeth  vary,  that  of  the 
molars  being  obliquely  forwards  toward  the  incisors  while 
the  crowns  of  the  premolars  are  directed  obliquely  back- 


PI.ATE  I. 
EXTRACTION  OF  TEETH. 

Sagittal  section  through  the  oral  cavity,  show- 
ing plan  for  extracting  the  first  inferior  molar, 
viewed  from  within  the  mouth. 


EXTRACTION  OF  TEETH.  7 

wards  from  the  incisors.  The  slant  of  the  teeth  is  most 
marked  at  the  ends  of  the  row  and  at  the  middle  they 
acquire  a  practically  perpendicular  position.  In  drawing 
the  last  molar  the  forceps  will  generally  strike  against 
the  opposite  row  of  teeth  before  the  tooth  has  com- 
pletely emerged  from  its  socket  and  in  order  to  complete  its 
removal  it  may  be  necessary  to  take  a  deeper  hold  with  the 
forceps  or  remove  with  the  exporteur  forceps  or  with  the 
fingers.  In  young  horses  where  the  teeth  are  very  long  we 
have  found  it  impossible  to  complete  the  extraction  until  the 
tooth  had  been  divided  transversely  by  means  of  the  tooth 
cutting  forceps. 

With  the  premolars  the  fulcrum  is  placed  beneath  the  ex- 
tension beyond  the  jaws  of  the  forceps  which  through  its 
fulcrum  then  rests  upon  the  grinding  surface  posterior  to  the 
diseased  tooth  and  permits  it  to  be  withdrawn  obliquely  from 
before  backward  in  its  normal  line  of  direction. 

The  dangers  in  the  extraction  of  teeth  are  chiefly  : 

1.  The  fracture  of  the  tooth  crown  leaving  the  fang  still 
fixed  in  the  alveolus,  a  danger  not  infrequently  unavoidable 
when  the  crown  has  become  greatly  weakened  by  disease  so 
that  it  wants  the  power  of  resistance  necessary  to  its  extrac- 
tion ;  under  most  other  conditions  it  may  be  largely  guarded 
against  by  the  careful  securing  of  the  patient  in  a  manner 
to  effectively  prevent  sudden  throwing  of  the  head  while  the 
forceps  are   applied,  and  by  using   good    judgment  in   the 
amount  of  force  used  while  loosening  the  tooth  in  its  alveolus. 

2.  Fracture  of  the  alveolar  walls  is  an  accident  which  may 
generally  be  prevented  by  proper  care  in  the  application  of 
force  and  the  avoidance  of  any  attempt  to  extract  a  tooth 
when  the  existence  of  an  enlargement  of  the  fang  is  apparent 
or  suspected. 

3.  The  tooth  may  slip  from  the  forceps  into  the  pharynx 
and    be  swallowed,  an  accident  avoidable  by  inserting  the 
hand  into  the  mouth  along  with  the  forceps  as  the  tooth  be- 
gins to  emerge  and  if  need  be  grasp  it  with  the  fingers. 


PI,ATE  II. 
EXTRACTION  OF  TEETH. 

Sagittal  section  through  the  walls  of  the  oral 
cavity  illustrating  plan  for  extracting  the  sec- 
ond superior  premolar. 


REPULSION  OF  TEETH.  1 1 

2.  REPULSION  OF  TEETH. 
PI.ATE  III. 

Uses.  The  removal  of  molars,  pre-molars,  tooth  fangs 
from  which  the  crowns  have  been  broken  away,  alveolar 
odontomes,  etc.,  which  can  not  be  removed  safely  by  means 
of  the  forceps. 

Instruments.  Razor,  convex  scalpels,  trephine,  bone 
gouge,  Luer's  sharp  bone  forceps,  light  and  heavy  bone 
chisels,  mallet,  tooth  punch,  curette,  compression  artery 
forceps,  scissors,  needles,  thread,  absorbent  cotton,  antiseptic 
gauze,  extracting  forceps,  splinter  forceps,  dressing  forceps, 
tenacula,  metal  probe,  mouth  speculum. 

Technic.  Secure  the  animal  in  the  lateral  recumbent 
position  with  the  affected  side  up.  The  operating  table 
affords  by  far  the  best  means  for  securing  for  the  conven- 
ience and  safety  of  operator  and  patient.  If  the  sinuses  are 
so  involved  as  to  make  possible  the  inhalation  of  pus,  blood 
or  other  injurious  matter,  perform  tracheotomy  in  ample 
time  to  avert  danger.  Anaesthetize.  Shave  and  disinfect 
the  operative  area  and  trephine  according  to  the  method 
described  in  the  following  chapter  down  through  the  alveolar  - 
plate  immediately  over  the  fang  of  the  affected  tooth.  Avoid 
dulling  the  trephine  by  striking  it  against  the  tooth  fang 
itself.  If  a  tooth  fistula  exists  the  identity  of  the  affected 
tooth  is  best  determined  by  passing  a  metallic  probe  through 
the  fistula  against  the  diseased  fang  while  one  hand  is  passed 
into  the  mouth  and  the  location  of  the  probe  ascertained. 
Care  should  be  exercised  in  trephining  to  not  injure  the  ad- 
joining teeth.  After  removing  the  disc  of  bone  isolated  by 
the  trephine,  control  all  hemorrhage  and  then  enlarge  the 
opening  and  remove  the  bony  tissues  till  the  tooth  fang  is 
bared  its  entire  width.  Insert  a  scalpel  between  the  bone  and 
soft  tissues  at  the  margin  of  the  trephine  opening  nearest  the 


12  REPULSION  OF  TEETH. 

mouth  and  with  one  hand  in  the  oral  cavity  with  the  fingers 
resting  upon  the  alveolar  border  on  the  lateral  side  of  the 
tooth  to  serve  as  a  guide,  push  the  scalpel  along  between 
the  bone  and  soft  tissues  until  it  emerges  from  the  gums 
alongside  the  affected  tooth  and  extend  this  incision  back- 
wards and  forwards  until  the  soft  tissues  are  completely  de- 
tached from  the  alveolar  wall  over  the  entire  area  of  the 
diseased  member.  With  a  light,  narrow  bone  chisel  cutaway 
and  remove  the  entire  external  alveolar  plate  throughout 
the  extent  of  the  tooth,  from  the  oral  margin  of  the  trephine 
opening  into  the  mouth  cavity.  Hold  the  chisel  so  that  the 
outer  edge  is  inclined  from  the  affected  tooth  toward  the 
adjoining  one,  thus  making  a  bevelled  channel  through  the 
alveolar  plate  which  tends  to  loosen  and  detach  the  section 
of  the  alveolar  wall  to  be  removed  without  injury  to  that 
adjoining.  Drive  the  chisel  for  a  short  distance  only  on  one 
side  and  then  apply  it  to  the  other  side  in  order  to  detach 
but  small  pieces  of  bone  at  one  time  avoiding  the  detachment 
of  large  sections  of  the  plate  at  once  and  having  it  extend  to 
neighboring  alveoli.  With  gouge  and  chisel  remove  all 
remnants  of  bone  over  the  lateral  side  of  the  tooth  laying  it 
completely  bare  as  shown  in  Plate  III.  The  soft  tissues  of 
the  part  should  not  be  disturbed  beyond  the  removal  of  the 
circular  piece  over  the  disk  of  bone  removed  by  the  trephine 
and  detatching  them  from  the  portion  of  bone  to  be  chiseled 
away.  When  the  tooth  has  been  bared  so  that  every  part  of 
its  lateral  surface  can  be  seen  or  felt,  the  punch  may  be  placed 
against  the  end  of  the  fang,  a  few  firm,  quick  blows  given 
with  the  mallet,  so  directed  that  the  force  is  in  a  line  with 
the  long  axis  of  the  tooth,  driving  it  into  the  mouth  where 
it  is  seized  by  the  forceps  or  the  hand  and  removed.  If  it 
is  not  readily  and  safely  dislodged  in  this  way,  place  the 
heavy  bone  chisel  against  it  and  with  the  aid  of  the  mallet 
comminute  the  tooth  by  breaking  it  transversely  and  splitting 
it  longitudinally,  in  which  process  the  fragments  are  gener- 


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1 6  REPULSION  OF  TEETH. 

ally  loosened  and  can  then  be  readily  removed  with  the  aid 
of  the  gouge  or  forceps.  Remove  carefully  all  fragments  of 
tooth  or  of  loosened  bone,  cleanse  and  disinfect  the  wound, 
pack  with  iodoform  gauze  and  dress  daily. 

In  cases  where  a  fistulous  opening  remains  after  repulsion 
of  molars  in  the  usual  manner  without  the  removal  of  the 
alveolar  wall,  or  if  a  tooth  has  been  drawn  by  means  of  the 
forceps  and  the  alveolus  fails  to  heal,  the  bony  plate  should 
be  removed  in  the  same  manner  as  indicated  for  the  removal 
of  the  teeth. 

Dangers.  Wounding  of  neighboring  teeth,  fracture  of 
the  inferior  maxilla,  fracture  of  the  bony  palate. 

Wounding  of  the  adjoining  tooth  is  to  be  avoided  chiefly 
by  carefully  locating  the  fang  of  the  affected  one  and 
placing  the  center  of  the  trephine  as  exactly  as  possible  over 
the  center  of  the  tooth,  by  using  a  trephine  not  exceeding 
2  to  2.5  cm.  in  diameter  and  cautiously  trephining  through 
the  compact  layer  of  the  external  plate  only,  removing  the 
cancellated  tissue  with  the  gouge  and  extending  the  opening 
in  the  desired  direction  after  the  outlines  of  the  tooth  fang 
have  been  clearly  determined.  If  an  adjoining  fang  is 
wounded  the  tooth  should  be  removed  as  it  will  not  heal  but 
will  result  in  a  permanent  tooth  fistula. 

The  fracture  of  the  alveolar  walls  of  the  inferior  maxilla  is 
to  be  constantly  guarded  against  by  being  cautious  to  see  after 
each  stroke  on  the  punch  that  it  has  not  slipped  inward  along 
the  median  side  of  the  tooth,  pressing  the  internal  plate  away 
from  the  tooth  row  and  tending  to  produce  a  longitudinal 
fracture  nearly  or  quite  as  long  as  the  dental  arcade.  Careful 
digital  exploration  in  the  mouth  may  discover  this  fracture 
while  still  "  simple  "  but  a  stroke  or  two  more  will  convert  it 
into  the  very  much  more  serious  "  compound  "  fracture  open- 
ing into  the  oral  cavity.  Keeping  one  hand  constantly  in  the 
mouth  at  the  point  of  impact  is  always  desirable  as  a  precau- 
tionary measure.  Transverse  fracture  of  the  tooth  while 


REPULSION  OF  TEE  TH.  1 7 

yet  in  situ  by  means  of  the  bone  chisel,  as  above  described, 
is  a  great  safeguard  against  this  injury  by  lessening  the  force 
required  in  repulsion  and  by  the  removal  of  the  tapering 
fang,  which  then  leaves  a  more  secure  base  for  the  punch  to 
act  upon.  It  should  never  be  forgotten  that  the  impact  from 
the  punch  must  always  be  as  nearly  parallel  to  the  long  axis 
of  the  tooth  as  is  possible. 

The  fracture  of  the  superior  maxilla  and  bony  palate  is 
not  so  probable  as  the  preceding  and  is  preventable  by  mod- 
erate care  in  the  baring  of  the  tooth  before  punching,  by 
comminution  of  the  tooth  in  bad  cases,  by  the  careful  ad- 
justment of  the  punch  and  applying  the  force  in  the  proper 
direction. 

Literature.  Odontomes,  Sir  Bland  Button,  Jour.  Comp. 
Med.  and  Vet.  Arch.  Vol.  XII,  p.  i  ;  A  Clinical  Study  of 
Odontomes,  W.  L.  Williams,  Am.  Vet.  Review,  Vol.  XV, 
p.  i  ;  Notes  on  Odontomes,  do  ;  Am.  Vet.  Rev.  Vol.  XXIII, 
p.  82  and  Oest.  Mon.  Thierheilkunde,  Bd.  XXIV,  s.  122. 


1 8  TREPHINING  OF  THE  FACIAL  SINUSES. 


TREPHINING  OF  THE  FACIAL  SINUSES. 
PIRATES  IV,  V,  VI,  VII. 

Prefatory  Note.  The  facial  sinuses  of  the  horse  consti- 
tute an  exceedingly  intricate  and  extensive  group  of  cavities, 
communicating  more  or  less  freely  with  each  other  and  with 
the  exterior  through  the  medium  of  the  upper  air  passages, 
of  which  they  are  to  be  regarded  as  a  part. 

Their  arrangement  and  relations  permit  them  to  frequently 
become  the  seat  of,  or  central  figure  in  many  forms  of  disease 
which  require  for  their  differential  diagnosis,  amelioration  or 
cure,  the  operation  known  as  trephining.  Their  extent  and 
relations  to  each  other  and  to  surrounding  parts  varies 
greatly  with  age  and  may  be  profoundly  changed  as  a  result 
of  disease,  amounting  not  infrequently  in  the  frontal, 
superior  and  inferior  maxillary  sinuses  ceasing  to  exist  as 
separate  cavities  arid  becoming  merged  into  one  vast  diverti- 
culum.  Similar  changes  ma}7  occur  in  the  nasal  and  lur- 
binated  cavities.  The  general  position,  extent  and  relations 
of  these  are  indicated  by  Plates  IV,  V,  VI  and  VII. 

The  uses  of  trephining  are  in  a  measure  common  to  all 
the  cavities  involved  and  are  chiefly  for  the  relief  of 
empyema  of  the  cavities  involved,  necrosis  of  the  bony  or 
cartilaginous  walls,  tumors  of  various  kinds,  especially  dental 
tumors  in  the  young  and  malignant  growths  in  the  old, 
foreign  bodies  in  the  sinuses,  differential  diagnosis  of  diseases 
of  this  region,  etc. 

Veterinarians  trephine  the  sinuses  by  two  fundamentally 
different  plans;  with,  and  without  excision  of  the  cutaneous 
disk  corresponding  to  the  piece  of  bone  removed.  The  first 
is  generally  used  in  Great  Britain  and  North  America  while 
the  last  is  the  prevailing  method  in  continental  Europe  and 
other  parts  of  the  world.  The  reasons  for  these  variations  in 
method  have  not  been  given  so  far  as  we  know.  To  us 


TREPHINING  OF  THE  FACIAL  SINUSES.  19 

there  seem  to  be  adequate  reasons  for  preferring  the  excision 
of  the  cutaneous  disk.  We  regard  as  the  chief  considera- 
tions in  an  operation  the  following  :  the  avoidance  of  infec- 
tion ;  the  prevention  of  pain  during  the  operation  or  the 
after-treatment  ;  the  reduction  of  the  scar  to  a  minimum  ; 
rapidity  and  certainty  of  recovery  ;  convenience  in  operating 
and  dressing.  Infection  is  largely  dependent,  aside  from 
aseptic  operation  and  protective  dressing,  upon  the  area  of 
the  wound,  the  facility  for  maintaining  cleanliness  and  the 
degree  of  disturbance  to  the  tissues  while  being  dressed. 
The  wound  area  in  the  bone  is  alike  in  all  cases  but  that  in 
the  skin  varies  greatly.  Jf  we  take  as  a  type  the  usual  Ger- 
man technic  and  compare  it  with  that  given  below  we  would 
find  the  wound  areas  approximately  as  follows  :  in  the  Ger- 
man method,  an  incision  2. 7  in.  (7  cm.  )  long  which  assuming 
that  the  skin  is  f\  in.  thick  would  yield  an  area  of  2.7"  X  2  = 
5.4"  X  y\"  =  J  scl-  }u-  The  subctitem  is  then  separated 
from  the  periosteum  and  the  skin  drawn  apart  far  enough  to 
admit  of  the  insertion  of,  say,  a  -J"  trephine  giving  2  triangles 
each  having  a  base  of  2.7"  in.  and  a  perpendicular  of  yV'- 
or  an  area  of  2.7"  X  Ty  =  1.2  sq.  in.  ;  thus  giving  a  total 
wound  area  of  2.2  sq.  in.  Assuming  the  same  thickness  of 
skin  and  the  same  size  of  the  trephine  in  the  operation  as 
given  belovy  we  have  only  the  wound  caused  by  the  circular 
incision  which  would  measure  £"  X  3.1416  =  2.7"  in  cir- 
cumference X  y\"  =  .44sq.  in.  or  proportionately  the  wound 
area  in  the  soft  tissues  in  the  German  operation  to  that  given 
below  would  be  as  5:1. 

It  is  very  evident  that  the  technic  below  given  affords 
immeasureably  better  facility  for  maintaining  cleanliness  in 
the  wound  and  with  a  minimum  amount  of  insult  to  the 
tissues  in  the  process  of  dressing. 

The  amount  of  pain  caused  in  the  operation  would  depend 
chifly  on  the  extent  of  the  skin  incision  which  is  equal  in 
the  two  plans  so  that  the  only  difference  would  be  in  the  dis- 


20  TREPHINING  OF  THE  FACIAL  SINUSES. 

section  of  the  skin  from  the  bone  in  the  German  operation. 
The  pain  caused  in  dressing  must  be  greater  in  the  German 
method  because  the  detached,  overhanging  skin  must  be 
moved  and  disturbed  each  time  causing  pain  and  inviting 
infection.  The  question  of  pain  must  always  be  seriously 
considered  as  it  not  only  affects  the  time  required  for  dressing 
and  its  efficacy,  but  has  an  important  relation  to  the  docility 
of  the  animal  after  recovery,  some  horses  having  their  dis- 
positions permanently  ruined  by  the  irritation  due  to  the  oft 
repeated  painful  dressing  of  wounds. 

The  cicatricial  contraction  of  the  tissues  of  the  horse  is 
so  great  that  the  removal  of  a  circular  disk  of  skin  "/%"  to 
i%"  in  diameter  on  the  face  does  not  leave  a  visible  scar  so 
that  the  question  of  blemish  falls  back  upon  that  of  infec- 
tion which  we  have  asserted  above  is  far  more  probable  by 
the  German  method. 

The  rapidity  and  certainty  of  recovery  are  dependent  on 
considerations  above  discussed.  The  removal  of  the  cuta- 
neous disk  is  certainly  easier  and  quicker  than  the  other 
method.  The  convenience  for  dressing  is  evidently  superior 
by  the  English  and  Amercan  method. 

The  opening  of  the  maxillary  sinuses  into  the  nostrils  is 
based  upon  the  surgical  principle  that  suppurating  cavities 
should  be  provided  with  ample  drainage  from  the  most  de- 
pendent part.  The  direction  to  leave  the  external  wound 
open  may  at  first  thought  seem  antagonistic  to  general  sur- 
gical principles  but  it  should  be  remembered  that  the  wound 
consists  only  of  the  incision  through  the  skin,  connective 
tissue  and  bone  and  that  any  plug  which  we  can  put  in  this 
opening  can  only  serve  to  dam  the  secretions  of  the  cavity 
back  and  can  not  prevent  it  from  coming  in  contact  with  the 
wounded  surface.  It  must  further  be  regarded  that  the 
respirator)'  mucosa  of  the  upper  air  passages  are  not  irritated 
or  injured  in  any  manner  so  far  as  we  can  observe  clinically 
by  the  direct  admission  of  air  into  them  through  a  trephine, 
or  other  artificial  opening. 


TREPHINNIG  OF  THE  FRONTAL  SINUSES.       21 


3.  TREPHINING  OF  THE  FRONTAL  SINUSES 

Uses.     Fracture  of  the  bony  walls,  necrosis,  tumors. 

The  ample  communication  below  with  the  superior  maxil- 
ary  sinuses  prevents  the  accumulation  of  pus  or  fluids  in  the 
frontal  cavities  even  if  formed  therein  unless  the  opening 
between  the  superior  maxilary  sinus  and  the  nasal  fossa  at  N, 
Plates  V  and  VI  becomes  blocked,  preventing  the  escape 
of  fluids  through  the  latter  and  causing  them  to  fill  the 
superior  maxilary  sinus  and  then  back  up  into  the  frontal. 
In  case  of  empyema  of  the  frontal  sinus,  trephining  does  not 
give  full  relief  but  calls  for  a  repetition  of  the  operation  on 
the  maxilary  sinuses  also. 

Instruments.  Razor,  scissors,  convex  scalpels,  artery 
forceps,  tenacula,  probe,  trephine,  curette,  gouge,  Luer's 
sharp  bone  forceps,  hammer,  chisel,  bone  screw,  lens-shaped 
bone  knife,  probe-pointed  bistoury,  dressing  forceps,  disin- 
fecting and  dressing  materials. 

Technic.  Operate  on  the  standing  animal  with  the  aid 
of  the  twitch  or  secured  in  stocks,  with  local  anaesthesia  or 
secure  on  the  operating  table  or  cast  in  lateral  recumbency  on 
the  sound  side.  Clip  and  shave  the  hair  from  the  region  of 
the  frontal  bone  on  a  level  with  the  superior  border  of  the 
orbital  cavity  as  indicated  in  Plate  IV  and  disinfect  the  area 
carefully.  Within  the  shaved  and  disinfected  area  locate  the 
point  for  trephining,  F,  Plate  IV,  so  that  the  inferior  border 
of  the  opening  will  be  on  a  level  with  the  superior  border  of 
the  orbital  cavity  at  the  dotted  line  below  F  and  the  inner 
margin  about  i  cm.  from  the  median  line  of  the  face.  With 
a  heavy  convex  scalpel  make  a  circular  incision  as  large  as 
the  area  of  the  trephine,  directly  through  the  skin,  subcutem 
and  periosteum  down  to  the  bone  and  remove  in  one  piece 
the  entire  mass  of  encircled  soft  tissues  by  seizing  the  skin 
with  a  tenaculum  and  forcibly  separating  the  periosteum 


PLATE  IV. 
TREPHINING  THE  FACIAL  SINUSES. 

F,  opening  into  frontal  sinus  ;  N,  opening 
into  nasal  sinus  ;  SM,  opening  into  superior 
maxillary  sinus  ;  IM,  opening  into  external  por- 
tion of  inferior  maxillary  sinus  ;  IM',  opening 
into  the  median  portion  of  the  inferior  max- 
illary sinus. 


*4- SM 


IM 


—  — IM 


BRA 

OF  THE 

UNIVERSITY 


TREPHINING  OF  THE  FRONTAL  SINUSES.        25 

from  the  bone  with  a  scalpel  or  bone  scraper.  Control  the 
hemmorhage.  With  the  center-bit  extended  place  the  tre- 
phine accurately  upon  the  denuded  area,  perpendicular  to 
the  surface  of  the  bone,  and  by  revolving  it  to  and  fro  force 
the  center-bit  into  the  bone  and  continue  until  the  trephine 
has  cut  a  distinct  furrow,  when  the  center-bit  should  be 
withdrawn  and  the  operation  continued,  being  careful  to 
maintain  the  trephine  perpendicular  to  the  bone.  The  ope- 
ration is  facilitated  by  grasping  the  shaft  of  the  trephine  be- 
tween the  thumb  and  fingers  of  one  hand,  constituting  a 
support  in  which  it  can  glide  back  and  forth.  The  pressure 
under  which  the  sawing  is  carried  out  must  not  be  too  great. 
When  the  bony  plate  which  has  been  sawed  around  begins 
to  loosen,  remove  the  trephine  and  insert  the  bone  screw 
into  the  centerbit  opening  and  break  out  the  piece  of  bone 
or  pry  it  out  with  the  bone  gouge  or  chisel.  Smooth  any 
uneven  edges  of  bone  with  the  lens-shaped  knife.  The  ab- 
normal contents  of  the  frontal  sinus  can  now  escape  through 
the  opening  or  be  removed  with  the  curette,  forceps  or  scis- 
sors, and  the  cavity  irrigated  with  an  antiseptic  fluid.  Leave 
the  trephine  wound  entirely  open  and  dress  daily  with  anti- 
septics.^ The  frontal  sinuses  are  in  free  communication  with 
the  superior  maxillary  and  with  the  superior  turbinated  bone 
of  the  same  side  so  that  indirectly  the  irrigating  fluid  can 
escape  through  the  nasal  opening  by  way  of  the  maxillary 
sinus  or  of  a  perforation  through  the  superior  turbinated 
bone. 

In  order  to  prevent  the  aspiration  of  the  contents  which 
are  generally  purulent,  or  ma}'  consist  of  blood  or  irri- 
gating fluids,  and  to  facilitate  their  escape,  irrigation 
must  be  carried  out  with  the  poll  elevated  and  the  head 
flexed. 

By  studying  Plates  IV  and  V  it  will  be  seen  that  any 
collection  of  pus  or  other  disease  products  at  F  would 
result  in  poor  drainage  so  far  as  may  be  obtained  by 


PLATE  V. 
TREPHINING  THE  FACIAL  SINUSES. 

Cross  section  of  the  left  side  of  the  head  of  an 
aged  horse  at  the  second  molar,  seen  from  the 
front.  F,  frontal  sinus  ;  N,  nasal  sinus,  oppo- 
site the  communication  between  the  nasal  and 
inferior  maxillary  sinuses  ;  IM,  lateral  portion 
of  inferior  maxillary  sinus  ;  IM/,  median  portion 
of  inferior  maxillary  sinus  ;  SM,  superior  max- 
illary sinus  ;  NF,  superior  maxillary  division  of 
trifacial  nerve  in  its  bony  conduit;  SZ,  subzygo- 
matic  artery  ;  P,  palatine  artery  ;  M2,  second 
molar. 


F 


F — J 


TREPHINING  OF  THE  FRONTAL  SINUSES.         29 

trephining  through  the  external  wall  only,  and  consequently 
in  order  to  complete  the  drainage  aside  from  that  through 
the  superior  maxillary  sinus  an  artificial  communication  be- 
tween the  frontal  sinus  and  nasal  fossa  may  be  made  at  ST, 
Plate  VII,  by  first  making  a  second  trephine  opening  op- 
posite that  point  near  the  median  line  and  then  breaking 
through  the  thin  walls  of  the  turbinated  bone  by  means  of 
a  probe  or  other  suitable  instrument  and  enlarging  the  open- 
ing sufficiently  with  the  probe  pointed  bistoury  or  with  the 
finger.  In  order  to  prevent  aspiration  of  fluids,  the  animal 
must  be  allowed  to  get  up  immediately  or  if  under  anaes- 
thesia a  trachea  tube  should  be  inserted  sufficiently  early  to 
avoid  danger.  Thread  a  long  probe  with  a  heavy  silk  suture 
about  75  cm.  long  and  inserting  it  through  the  trephine 
opening  into  the  nasal  passage  draw  it  out  through  the 
nostril  and  removing  the  probe  attach  a  strip  of  gauze 
75  cm.  long  to  one  end  of  the  suture,  draw  it  out  through 
the  nostril  and  tie  the  ends  of  the  gauze  together  on  the  side 
of  the  face  to  prevent  dislodgement.  Retain  the  gauze 
in  position  for  about  forty-eight  hours  to  insure  the  per- 
manency of  the  opening  through  the  turbinated  bone.  In 
case  of  severe  hemorrhage  the  cavity  can  be  tamponed  for 
twenty-four  hours  with  a  long  strip  of  gauze  which  may 
be  secured  if  necessary  by  suturing  to  the  lips  of  the  wound. 
In  practice  the  operation  can  be  best  carried  out  generally 
with  the  animal  in  the  standing  position  the  operative  area 
being  first  anaesthetized  by  the  use  of  cocaine  or  by  inducing 
artificial  oedema.  In  the  standing  position  we  largely  avoid 
the  danger  of  aspiration  of  fluids  and  the  hemorrhage  is 
greatly  lessened. 


PI.ATE  VI. 
TREPHINING  THE  FACIAL  SINUSES. 

Cross  srction,  slightly  oblique,  through  left 
half  of  head  at  fiist  molar  in  a  two  year  colt. 
F,  frontal  sinus  ;  N,  nasal  sinus  at  point  of  com- 
munication with  the  inferior  maxillary  sinus, 
IM  ;  IM',  median  portion  of  inferior  maxillary 
sinus;  SM,  superior  maxillary  sinus  ;  Mi,  first 
molar  ;  M2,  second  molar  ;  P,  palatine  artery  ; 
SZ,  sub-zygomatic  arttry. 


F 


INF 


—  SM 


PAWfiMl 
~~>^         '    ' 


TREPHINING  THE  MAXILLARY  SINUSES.         33 


4.  TREPHINING  THE  MAXILLARY  SINUSES. 

Uses.     Empyema,  diseased  teeth,  odontomes,  tumors. 

Instruments.     Same  as  for  the  frontal  sinuses. 

Anatomically  there  are  two  maxillary  sinuses,  superior 
SM,  and  inferior  IM,  Plates  IV,  V,  and  VI,  having  a  thin 
imperforate  bony  partition  between  them.  This  partition 
shifts  somewhat  in  position  with  age  and  in  case  of  disease 
undergoes  profound  changes  in  location  and  is  frequently 
totally. obliterated  in  cases  of  empyema,  dental  cysts  and 
other  affections,  so  that  clinically  in  many  cases  its  location, 
existence  or  non-existence  is  of  scant  interest.  If  present, 
good  drainage  of  the  superior  sinus  usually  demands  its 
surgical  destruction  so  that  most  authors  advise  trephining 
directly  over  this  partition  in  order  to  open  the  two  sinuses 
simultaneously.  In  extensive  disease  the  prior  destruction 
of  the  partition  renders  such  an  operation  superfluous  ;  in 
limited  disease  the  opening  of  both  cavities  is  ill  advised. 
The  partition  should  be  ignored  in  operating  for  extensive 
disease  and  the  trephine  opening  be  aimed  at  the  probable 
focus  of  disease  and,  if  missed,  it  should  be  located  through 
the  primary,  or  what  now  becomes  an  exploratory  opening 
and  a  second  operation  made  to  directly  reach  the  seat  of  the 
affection  and  if  need  be,  yet  a  third  to  secure  proper  drain- 
age. Shave  and  disinfect  as  much  of  the  area  as  may  be  re- 
quired bounded  above  by  the  inferior  border  of  the  orbital 
cavity,  laterally  by  the  zygomatic  ridge,  inferiorly  by  the 
lower  end  of  the  zygomatic  ridge  and  medianwards  by  the 
middle  line  of  the  face.  Determine  the  proper  point  for 
operation  by  percussion  or  otherwise.  If  it  is  desired  to 
enter  only  the  superior  maxillary  sinus,  SM,  Plates  V  and 
and  VI,  locate  the  opening  immediately  beneath  the  orbital 
cavity  and  in  front  of  the  zygomatic  ridge,  SM,  Plate  IV,  or 
at  any  point  directly  beneath  this  to  within  about  3  or  4  cm.  of 
3 


34         TREPHINING  THE  MAXILLARY  SINUSES. 

the  inferior  end  of  the  zygomatic  ridge  at  about  the  level  of 
the  dotted  line  IM'.  In  order  to  penetrate  the  inferior 
maxillary  sinus  the  trephine  opening  needs  be  located  just 
in  front  of  the  lower  end  of  the  zygomatic  ridge  at  IM,  Plate 
IV,  or  on  a  line  obliquely  upwards  therefrom  as  far  as  the 
furrow  marking  the  suture  between  the  maxillary  and  nasal 
bones  at  IM'.  The  trephining  is  carried  out  as  described 
for  the  frontal  sinuses.  After  the  trephine  opening  has  been 
made  remove  any  purulent  collection  or  tumors  or  carry  out 
any  other  necessary  operation  in  the  affected  sinuses  and 
after  cleansing,  if  the  trephine  opening  does  not  insure  per- 
fect drainage  of  the  lateral  sac,  either  lower  the  opening 
already  made  by  cutting  away  its  inferior  border  with  the 
bone  forceps  or  make  a  second  trephine  opening  at  the  neces- 
sary point.  The  median  portion  of  the  sinuses  on  the 
median  side  of  the  bony  conduit  of  the  trifacial  nerve  NF, 
Plates  V  and  VI,  can  not  be  drained  properly  through  these 
openings  SM  and  IM,  Plate  IV,  and  provision  for  their 
drainage  must  generally  be  made  by  making  a  trephine  open- 
ing into  the  inferior  maxillary  sinus  at  IM',  Plate  IV,  and 
then  make  an  opening  3  to  5  cm.  in  diameter  through  the  in- 
ferior turbinated  bone  at  IT,  Plate  VII,  either  with  the 
ringer,  probe-pointed  bistoury,  or  other  suitable  instrument, 
and  inserting  through  this  opening  a  long  and  thick  strip  of 
gauze  which  is  brought  out  through  the  nostril  and  the  ends 
tied  together  on  the  side  of  the  face  to  prevent  displacement. 
Retain  this  in  position  renewing  daily  until  the  permanency 
of  the  opening  is  assured. 

If  the  partition  between  the  two  sinuses  is  intact  it  wrill  be 
necessary  to  destroy  it  immediately  above  IM',  Plate  IV,  in 
order  to  drain  the  median  portion  of  the  superior  maxillary 
sinus  if  that  is  required.  If  a  molar  has  been  removed  and 
in  so  doing  the  bony  wall  leading  down  from  the  nerve  con- 
duit NF,  Plates  V  and  VI,  to  the  fang  of  the  molar  has  been 
destroyed  in  the  operation,  sufficient  drainage  may  be  af- 


TREPHINING  THE  MAXILLARY  SINUSES.         35 

forded  into  the  mouth  and  the  opening  through  the  turbinated 
bone  be  rendered  unnecessary.  Leave  all  wounds  entirely 
open  and  irrigate  daily  with  antiseptic  solutions. 

Dangers.  Care  must  be  exercised  to  not  injure  the 
superior  maxillary  division  of  the  trifacial  nerve,  NF,  Plates 
V  and  VI,  either  in  trephining  or  after  the  sinuses  have 
been  opened.  The  bony  conduit  of  this  nerve  is  in  rare 
cases  entirely  resorbed  by  pressure  from  dental  cysts  or  other 
causes,  leaving  the  nerve  stretched  across  the  cavity  as  a 
white  nacrous  cord,  intensely  sensitive.  Any  injury  to  this 
'nerve  causes  intense  pain  and  renders  the  animal  very  re- 
sistant to  the  necessary  manipulations  in  the  after  care  of 
the  wound  and  may  leave  it  permanently  nervous  about  the 
handling  of  its  face. 

Hemorrhage  is  generally  not  severe  and  may  occur  from 
the  skin,  where  it  should  be  controlled  by  compression  or 
ligation  ;  from  the  inter-osseous  vessels,  where  it  may  be 
controlled  by  pressure  with  absorbent  cotton,  by  pushing  a 
small  portion  of  the  cotton  into  the  channel  of  the  vessel 
with  a  needle  or  tenaculum  or  by  plugging  the  vessel  with  a 
conical  piece  of  wood  ;  from  the  wounded  turbinated  bones 
where  it  may  be  controlled  by  packing  with  cheese  cloth. 
These  tampons  should  be  removed  after  twenty-four  hours. 


36  TREPHINING  THE  NASAL  FOSSAE. 


5.     TREPHINING  THE  NASAL  FOSSAE. 

Uses.  Operations  on  the  septum  nasii,  upon  the  tur- 
binated  bones,  the  removal  of  tumors  or  foreign  bodies. 

Instruments.     Same  as  for  the  frontal  sinuses. 

Technic.  The  trephining  is  carried  out  by  the  method 
described  above,  in  the  region  of  the  nasal  bone,  close  by 
the  median  line  of  the  face  and  according  to  indications  at 
any  point  from  a  level  of  the  dotted  line  SM,  Plate  IV,  to 
the  upper  extremity  of  the  false  nostril.  The  operation 
should  be  immediately  against  the  median  line  since  other- 
wise the  frontal  or  superior  turbinated  sinuses  may  be 
opened,  the  highly  vascular  superior  turbinated  bone 
wounded  or  an  important  inter-osseous  artery  in  the  nasal 
bone  just  above  its  union  with  the  superior  turbinated  bone, 
as  shown  in  Plate  VI,  may  be  severed.  Special  care  is  also 
necessary  that  the  trephining  should  not  be  carried  too 
deeply  and  that  the  disc  of  bone  be  carefully  removed  in 
order  to  avoid  wounding  the  highly  vascular  turbinated 
bone  which  lies  in  close  proximity  to  the  nasal  bone.  The 
operative  area  is  narrow  and  the  trephine  used  should  not 
exceed  2  cm.  in  diameter.  Whenever  possible  the  opera- 
tion should  be  carried  out  on  the  standing  animal  which  de- 
creases the  hemorrhage  and  the  danger  from  aspiration  of 
fluids.  Even  in  the  standing  animal,  if  extensive  operations 
are  to  be  carried  out  on  the  very  vascular  septum  nasii  or 
on  the  turbine  it  is  generally  advisable  to  perfoin  trache- 
otomy before  trephining,  and  retain  the  trachea  tube  in 
position  until  all  danger  has  passed.  When  the  animal  is 
confined  in  the  recumbent  position  the  patient's  safety  de- 
mands that  tracheotomy  be  performed  before  the  operation 
is  begun  in  almost  all  cases.  Anaesthesia  may  be  maintained 
in  such  cases  by  means  of  an  ordinary  funnel  with  its  spout 
bent  at  right  angles  and  inserted  into  the  trachea  tube  while 


POLL  EVIL  OPERATION.  37 

the  chloroform  is  dropped  on  a  towel  spread  over  the  mouth 
of  the  funnel.  After  completing  any  required  operation  on 
the  septum,  turbinated  bones  or  other  parts,  hemorrhage 
may  be  controlled  by  plugging  one  or  both  nasal  fossa  with 
single  strips  of  gauze  of  sufficient  size  and  carefully  se- 
curing them  by  sutures  to  the  sides  of  the  trephine  wound 
or  otherwise. 


6.     POLL  EVIL  OPERATION.  > 
PLATE  VII. 

Instruments.  Clipping  shears,  razor,  sharp  scalpels, 
probe-pointed  bistoury,  probe,  Luer's  bone  forceps,  bone 
gouge,  curette,  suture  and  dressing  material. 

Technic.  Confine  the  animal  in  lateral,  decubitis  prefer- 
ably upon  the  operating  table,  place  under  complete  anaes- 
thesia and  remove  the  halter  or  other  headgear.  Clip  the 
foretop  and  mane  and  shave  the  forehead  and  the  top  of  the 
neck  back  to  a  distance  of  8  or  10  cm.  and  behind  the  sup- 
posed extension  of  disease,  and  disinfect  the  area.  With  a 
sharp  scalpel  make  a  longitudinal  incision  on  the  median  line 
of  the  head  and  neck  beginning  at  a  point  presumably  posteri- 
or to  the  diseased  area  and  carrying  it  over  the  poll  down  onto 
the  forehead  for  a  distance  of  4  or  5  cm.  below  the  foretop. 
Continue  this  incision  through  the  skin,  the  subcutem,  the 
adipose  tissue,  AT,  Plate  VII,  and  either  through  or  passing 
around  alongside  the  neck  ligament,  L,N,  into  the  diseased 
area  beneath  the  latter.  Dissect  the  ligamentum  nuchae 
away  from  the  adjoining  tissues  as  far  back  as  diseased  and 
divide  obliquely  upward  and  backward  as  indicated  at  AA, 
Plate  VII  and  detach  anteriorly  from  the  base  of  the  occiput. 
Be  careful  to  remove  every  portion  of  the  ligament  in  the 
area  indicated  and  remove  all  calcareous  deposits  or  diseased 
tissues.  With  Luer's  forceps  groove  a  channel  about  2  cm. 
wide  from  behind  to  before  through  the  occipital  protuber- 


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or 
LIGA  TION  OF  THE  PAROflf^fJVCT.  41 

ance  to  the  depth  of  about  2  cm.  making  the  bottom  of  the 
groove  as  near  as  possible  on  a  level  with  the  bottom  of  the 
wound  in  the  soft  tissues  as  indicated  by  the  dotted  line,  AA, 
Plate  VII.  Using  Liter's  forceps  as  a  curette  detach  all 
vestiges  of  the  neck  ligament  from  the  base  of  the  occiput 
and  leave  the  bone  bare  and  smooth.  Be  careful  to  avoid 
penetrating  the  cranial  cavity  or  the  occipito-atloid  articula- 
tion. Control  the  hemorrhage,  cleanse  and  disinfect  the 
wound,  pack  with  iodoform  gauze  and  sutine  for  its  entire 
length  except  the  anterior  part  where  the  packing  should 
slightly  protrude  and  dust  the  margin  of  the  wound  over 
with  iodoform  and  tannin.  Remove  the  pack  after  forty - 
eight  hours  and  dress  antiseptically  daily.  The  sutures  may 
or  may  not  be  removed  according  to  conditions.  In  carrying 
out  this  operation  our  chief  aim  should  be  to  remove  all 
diseased  parts,  to  afford  perfect  drainage  anteriorly,  to  secure 
and  maintain  asepsis,  and  to  keep  the  wound  directly  on 
the  median  line  from  which  no  visible  scar  will  result. 


7.     LIGATION  OF  THE  PAROTID  DUCT. 
PLATE  VIII. 

Objects.  The  destruction  of  the  parotid  gland  in  case  of 
fistula  from  wounds  or  abscesses. 

Instruments.  Razor,  convex  scalpel,  straight  probe- 
pointed  scalpel,  teiiaculiini  forceps,  ligation  forceps,  tenacula, 
needle  holder,  probe,  suture  and  dressing  material. 

Technic.  In  case  of  salivary  fistula  insert  a  probe 
through  the  fistula  into  the  duct  toward  the  gland  and  with 
a  sharp  scalpel  la)*  the  parotid  duct  free  for  a  distance  of 
from  i  to  2  cm.  on  the  glandular  side  of  the  fistulous  open- 
ing. If  the  fistula  has  its  location  on  the  side  of  the  cheek, 
cast  the  horse  and  shave  and  disinfect  the  region  on  the 
inferior  maxilla  where  the  artery,  vein  and  parotid  duct 
turn  around  its  inferior  border.  When  the  operator  glides 
his  finger  over  the  vascular  region  from  before  backward 


Pl,ATE  VIII. 
LlGATlON  OF  THE  PAROTID  DUCT. 

Fig  i.  Segment  of  the  left  ranms  of  the  in- 
ferior maxilla  of  the  horse  seen  from  the  right 
and  beneath,  sp,  usual  operative  field  ;  «,  ex- 
ternal maxillary  artery  ;  v,  external  maxillary 
vein  ;  st,  st,  parotid  duct. 

Fig.  2.  Life  size  of  operation  field  at  sp,  fig.  i  ; 
fl,  external  maxillary  artery  ;  v,  external  maxil- 
lary vein  ;  st,  parotid  duct ;  m,  masseter  muscle. 


FIG    i. 


FIG   2 


O 8*4*7 
OF  THE 

UNIVERSITY 

OF 


LIGATION  OF  THE  PAROTID  DUCT.  45 

there  is  felt  a  resistant  cord,  the  external  maxillary  artery 
about  3  mm.  in  diameter,  pulsating  in  the  living  animal. 
Between  this  and  the  oral  border  of  the  masseter  muscle  make 
an  incision  about  4  cm.  long  parallel  with  the  artery  through 
the  skin  and  skin  muscle.  This  incision  is  more  readily 
made  by  gathering  up  a  fold  of  skin  about  2  cm.  high  and 
cutting  through  this.  Pick  up  the  loose  connective  tissue 
with  a  pair  of  forceps  and  excise  it.  Immediately  behind 
the  external  maxillary  artery,  a,  Figs.  I  and  II,  Plate  VIII, 
is  the  external  maxillary  vein  v  and  behind  this  and  immedi- 
ately on  the  border  of  the  masseter  muscle  lies  the  parotid 
duct,  st.  In  case  ot'  salivary  calculi  which  cannot  be  re- 
moved through  the  mouth  and  cystic  dilation  of  the  par- 
otid duct,  make  the  cutaneous  incision  at  the  affected 
point,  open  the  parotid  duct,  and  after  the  removal  of  the 
calculus,  etc.,  close  the  duct  wound  by  means  of  intestinal 
sutures  in  such  a  way  that  the  external  surfaces  of  the  lips 
of  the  wound  in  the  wall  of  the  duct  are  brought  in  contact, 
or  ligate  the  duct  on  the  proximal  side  of  the  point  of  opera- 
tion. Legation  is  accomplished  by  passing  a  strong  silk 
thread  behind  the  duct  by  means  of  a  curved  needle  carry- 
ing it  around  the  duct  and  tying  with  a  surgeon's  knot. 
The  parotid  duct  can  also  be  previously  split  and  an  internal 
wound  made  at  the  point  of  ligation.  Close  the  skin  wound 
by  means  of  a  continuous  suture  and  cover  the  operative 
surface  with  iodoform  collodion  or  with  wound  gelatine. 


46  ENTROPIUM  OPERATION. 

8.     ENTROPIUM    OPERATION. 

Instruments.  Razor,  convex  scalpel,  tenaculum  and 
ligation  forceps,  tenacula,  needle  holder,  needles,  thread, 
absorbent  cotton. 

Technic.  Quiet  adult  horses  may  be  operated  upon  in 
the  standing  position  with  the  aid  of  local  anaesthesia,  other 
horses  and  small  animals  should  be  secured  in  lateral  re- 
cumbency preferably  upon  the  operating  table.  Shave  and 
disinfect  the  skin  of  the  inverted  eyelid.  Grasp  the  skin  of 
the  eyelid  midway  between  the  inner  and  outer  canthi 
either  with  the  fingers  or  the  forceps  and  elevate  a  skin  fold 
parallel  with  the  border  of  the  eyelid  to  such  a  height  that 
the  inverted  member  assumes  its  normal  position.  Pass 


FIG  i. 
Entropium  operation  on  the  superior  and  inferior  eyelids  of  the  dog. 

one  finger  into  the  conjunctival  sac  to  make  sure  that  the 
conjunctiva  is  not  drawn  into  the  skin  fold.  Clip  the  fold 
off  with  the  scissors  immediately  below  the  forceps,  remov- 
ing an  oblong  piece.  Between  the  border  of  the  eyelid  and 
the  border  of  the  wound  the  skin  should  be  left  intact  for  at 
least  .5  cm.  Ligate  any  bleeding  vessels  and  close  the 
wound  by  means  of  interrupted  sutures.  The  wound 
may  be  covered  with  iodoform  collodion  or  wound  gelatine 
or  dusted  over  with  iodoform-tannin.  It  is  usually  un- 
necessary and  inadvisable  to  cover  the  parts  with  hood  or 
other  appliance  since  so  long  as  the  wound  is  healing 
properly  the  animal  will  not  disturb  it. 


STAPHYLOTOMY.  47 


9.     STAPHYLOTOMY. 

Object.  An  operation  devised  by  Dr.  M.  H.  McKillip 
for  making  a  manual  exploration  of  the  Eustachian  tubes, 
guttural  pouches,  pharynx  and  posterior  nares  ;  and  for 
operations  upon  these  structures.  The  form  and  extent  of 
the  soft  palate  of  the  horse  is  such  as  to  render  it  extremely 
difficult  to  make  a  manual  exploration  of  the  parts  above 
and  behind  it,  and  impossible  to  make  a  visual  examina- 
tion except  with  the  aid  of  the  expensive  and  complicated 
rhino-laryngoscope,  which  only  aids  in  diagnosis  while 
staphylotomy  combines  with  this  operative  advantages,  per- 
mitting the  free  introduction  of  the  hand  into  the  laryngo- 
pharyngeal  region. 

Instruments.  Mouth  speculum,  short  curved  probe 
pointed  bistoury  with  a  ring  to  fit  the  middle  finger. 

Technic.  Cast  the  patient  or  secure  on  the  operating 
table  in  lateral  recumbency  and  turn  the  nose  upward. 
Adjust  the  mouth  speculum  and  open  the  mouth  as  wide  as 
possible  ;  draw  the  tongue  well  out  with  the  left  hand  while 
the  right  carrying  the  knife  on  the  middle  finger  is  passed 
carefully  through  the  fauces  until  it  hooks  over  the  posterior 
border  of  the  soft  palate.  /The  knife  is  then  gently  drawn 
forward  making  an  incision  along  the  median  line  of  the 
soft  palate  from  its  posterior,  free  border  to  its  attachment 
on  the  palatine  bone.  The  hand  is  then  withdrawn  and  the 
speculum  removed  for  a  few  minutes  to  permit  the  patient  to 
rid  its  pharynx  of  any  blood  clots  or  mucus  that  may  have 
accumulated.  Readjusting  the  speculum  as  before,  the 
right  hand  is  again  passed  through  the  fauces  and  now  that 
the  palate  is  divided  a  digital  exploration  will  perfectly  re- 
veal the  presence  of  any  abnormality  in  the  region. 


48  TRIFACIAL  NEUROTOMY. 

10.     TRIFACIAL  NEUROTOMY. 
PLATE  IX. 

Object.     The  relief  of  involuntary  shaking  of  the  head. 

Instruments.  Razor,  scissors,  convex  scalpel,  tenacula, 
aneurism  needle,  compression  artery  forceps,  needles,  thread, 
absorbent  cotton,  a  strong  piece  of  muslin  12  cm.  square. 

Technic.  Secure  in  lateral  recumbency,  preferably  upon 
the  operating  table,  and  produce  complete  anaesthesia.  Re- 
move the  halter,  bridle,  or  other  head  gear.  Shave  and  dis- 
infect an  area  8  to  10  cm.  square  over  the  infra-orbital  fora- 
men. Locate  by  touch  the  infra-orbital  foramen,  IOF,  Plate 
IX,  below  the  levator  labii  superioris  proprius  muscle  and 
displace  the  latter,  LL,  down  wards  toward  the  inferior  maxilla 
until  the  foramen  can  be  felt  above  the  muscle.  By  pushing 
this  muscle  downward  the  branches  of  the  glosso-facial 
vessels  which  lie  chiefly  below  it  are  pushed  downward  with 
the  muscle  so  that  the  incision  can  be  made  without  wound- 
ing them.  Begin  the  incision  i  cm.  above  the  foramen  and 
carry  it  down  directly  over  the  middle  of  the  nerve  a  distance 
of  5  or  6  cm.,  through  the  skin,  subcutem  and  the  levator 
labii  superioris  alaque  nasii  muscle,  laying  bare  the  nerve 
NF,  where  it  emerges  from  the  foramen.  Let  an  assistant 
hold  the  lips  of  the  wound  apart  and  the  levator  muscle 
downwards  with  two  tenacula,  dissect  away  the  connective 
tissue  surrounding  the  nerve  until  the  latter  is  clearly  de- 
fined, pass  the  aneurism  needle  beneath  the  nerve  from 
above  downwards  being  especially  careful  to  include  the 
uppermost  or  dorsal  twigs,  and  passing  a  curved  probe- 
pointed  scalpel  or  the  blade  of  a  pair  of  scissors  underneath 
it,  divide  the  nerve  at  the  foramen,  grasp  the  distal  end  with 
forceps  and  excise  a  piece  at  least  3  cm.  long  being  careful 
to  include  all  branches.  Control  the  hemorrhage  very  care- 
fully. Cleanse  the  wound,  sprinkle  with  iodoform  and  close 


TR I  FACIAL  NEUROTOMY.  49 

with  continuous  sutures.  Place  the  square  piece  of  muslin 
centrally  over  the  wound  and  fix  it  securely  to  the  .skin  by 
means  of  strong  sutures  at  each  corner,  in  order  to  protect  it 
while  the  other  nerve  is  being  cut.  Turn  the  animal  to  the 
opposite  side  and  repeat  the  operation  on  the  other  nerve 
except  the  application  of  the  square  piece  of  muslin  which 
is  here  unnecessary.  As  soon  as  the  animal  stands,  remove 
the  protective  piece  of  muslin  from  the  first  wound,  disinfect 
both  wounds,  dust  them  over  with  iodoform  and  tannin  or 
cover  with  wound  gelatine  and  leave  undisturbed  to  heal  by 
primary  union.  Avoid  halter,  bridle  or  other  fixtures  which 
might  injure  the  wounds  after  the  operation. 

Dangers.  The  chief  danger  in  the  operation  is  from  in- 
fection, which  sets  up  a  severe  neuritis  in  the  proximal  end 
of  the  nerve,  aggravates  the  symptoms  and  causes  much 
suffering.  In  order  to  prevent  infection  the  aseptic  precau- 
tions need  be  unusually  strict  in  every  detail  and  the  anaes- 
thesia profound.  Carefully  avoid  wounding  the  neighbor- 
ing vessels  and  control  completely  any  hemorrhage  that 
occurs  in  order  to  avoid  a  hematome  in  the  wound,  which 
would  invite  infection. 

Literature.  Involuntary  twitching  of  the  head  relieved 
by  trifacial  netirectomy.  W.  L,.  Williams,  Jour.  Comp. 
Med.  and  V.  A.,  vol.  XVIII,  p.  426.  Involuntary  shaking 
of  the  head  and  its  treatment  by  trifacial  neurectomy.  do. 
Am.  Vet.  Rev.,  vol.  XXIII,  p.  321  and  (Est.  Monatsch. 
Thierheilkunde,  Bd.  XXIV,  s.  211. 


PI.ATE  ix. 
TRIFACIAI,  NEUROTOMY. 

LL,  Levator  labii  superioris  proprii  displaced 
ventralwards  toward  inferior  maxilla.  It  origin- 
ally rested  at  end  of  dotted  line  from  IOF  ;  IOF, 
infra-orbital  foramen  ;  NF,  superior  maxillary 
division  of  the  trifacial  nerve. 


OPENING  OF  THE  GUTTURAL  POUCHES.  53 

II.     OPERATIONS  ON  THE  NECK. 

n.     OPENING  OF  THE  GUTTURAL  POUCHES. 

PI.ATE  X. 

Instruments.  Razor,  scissors,  convex  pointed  and 
straight  probe  pointed  scalpels,  artery  forceps,  tenacula 
probe,  trocar,  curette,  drainage  tubing,  suture  and  dressing 
material. 

Technic.  I.  Viborg's  method.  The  operation  is  possible 
on  the  standing  animal,  but  generally  the  patient  must  be 
cast  or  placed  on  the  operating  table  and  secured  in  lateral 
decubitis  with  the  head  extended.  By  extending  the  head 
and  compressing  the  jugular  vein  there  is  brought  out  the 
triangle  immediately  behind  the  posterior  border  of  the  in- 
ferior maxilla  and  below  the  parotid  gland  comprised  be- 
tween the  posterior  angle  of  the  inferior  maxilla,  the  terminal 
tendon  of  the  sterno-maxillaris  muscle  and  the  external 
maxillary  vein.  In  this  so-called  Viborg's  triangle  after  the 
removal  of  the  hair  and  the  disinfection  of  the  skin  which 
is  maintained  stretched,  make  a  5  cm.  long  incision  through 
the  skin  and  skin  muscle  immediately  beneath  the  afore- 
mentioned tendon  and  parallel  to  it.  In  case  of  pronounced 
swelling  in  Viborg's  triangle  the  operator  must  determine 
the  location  for  the  incision  by  the  position  of  the  sterno- 
maxillaris  muscle.  The  skin  and  subcutem  having  been 
incised  to  a  sufficient  extent,  force  a  passage  with  the  finger 
or  with  probe  pointed  scissors  closed  or  other  blunt  instru- 
ment through  the  loose  connective  tissue  on  the  median  side 
of  the  parotid  gland,  which  area  is  free  from  large  vessels 
and  nerves,  to  the  guttural  pouch  and  penetrate  it  at  its 
lowest  point  with  the  finger  or  trocar.  In  order  to  open 
the  empty  guttural  pouch  it  is  desirable  to  grasp  a  portion 
of  its  wall  by  means  of  forceps.  Through  the  operative 


PLATE  X. 

OPENING  OF  THE  GUTTURAL  POUCHES  (Hvo- 

VERTEBROTOMY)  ACCORDING  TO  VIBORG 

AND  CHABERT. 

Head  and  neck  of  recumbent  horse  viewed 
from  the  side,  sin,  Stylo  maxillaris  muscle  ;  p, 
parotid  gland  ;  /,  guttural  pouch  ;  k,  larynx  ; 
st,  sterno-maxillaris  muscle  ;  r,  rectus  capitus 
anticus  major  muscle  ;  £,  external  carotid  artery  ; 
<?,  external  maxillary  artery  ;  /,  internal  maxil- 
lary artery ;  v,  external  maxillary  vein  ;  s, 
probe  ;  a,  wing  of  atlas. 


UNIVERSITY 

or 


OPENING  OF  THE  GUTTURAL  POUCHES.  57 

wound  a  drainage  tube  can  be  introduced  into  the  pouch, 
and  fixed  in  its  position  by  sutures.  The  opening  can  be 
enlarged  in  an  anter-posterior  direction  to  the  extent  of  5  to 
8  cm. 

A  far  more  common  operation  in  veterinary  practice 
than  the  opening  of  the  guttural  pouches,  is  the  opening  of 
abscesses  of  the  sub-parotid  lymph  glands,  lying  between  the 
inner  face  of  the  parotid  and  the  external  face  of  the  guttural 
pouch.  The  operation  here  used  is  the  same  as  Viborg's 
for  the  guttural  pouch  but  does  not  penetrate  that  cavity 
because  the  inner  wall  of  the  abscess  has  pushed  the  ex- 
ternal wall  of  the  pouch  inward  so  that  the  former  largely 
occupies  the  usual  location  of  the  guttural  pouch.  The 
dyspnoea  generally  prohibits  casting  the  animal  and  neces- 
sitates operating  in  the  standing  position.  In  some  cases 
the  dyspnoea  is  so  severe  as  to  demand  tracheotomy  before 
the  opening  of  the  abscess  can  be  undertaken  because  the  ex- 
citement aggravates  the  difficult  respiration  to  the  point  of 
suffocation. 

II.  Chaberf  s  method.  Secure  the  horse  in  the  lateral  re- 
cumbent position,  remove  the  hair  and  disinfect  the  skin 
beneath  the  wing  of  the  atlas.  Make  an  incision  about  i 
cm.  in  front  of  the  lower  half  of  the  wing  of  the  atlas  and 
parallel  to  it,  about  6  cm.  long  extending  through  the  skin 
and  skin  muscle  down  to  the  parotid  gland.  The  incision 
is  facilitated  by  rendering  the  skin  tense  with  the  left  hand 
and  care  is  to  be  taken  not  to  wound  the  auricular  nerve 
which  passes  directly  along  the  atlas.  Then  draw  backward 
the  posterior  lip  of  the  wound  and  separate  with  blunt  in- 
struments the  posterior  border  of  the  parotid  gland  from  the 
atlas,  to  which  it  is  bound  by  loose  connective  tissue,  and 
draw  the  gland  forward  with  tenacula.  At  the  bot- 
tom of  the  opening  thus  formed  there  is  seen  the  stylo- 
maxillaris  muscle,  sm,  Plate  X,  lying  against  the  median 
side  of  the  parotid  gland  covered  only  by  the  aponeurosis  of 
the  mastoido-humeralis  muscle.  With  the  handle  of  the 


58  OPENING  OF  THE  GUTTURAL  POUCHES. 

scalpel  inclined  toward  the  wing  of  the  atlas  penetrate  in  the 
direction  of  their  fibers  the  aponenrotic  expansion  of  the 
mastoido-humeralis  muscle  and  the  sterno  maxillaris  muscle. 
The  puncture  is  thus  located  between  the  ninth  and  tenth 
nerves  on  one  side  and  the  internal  carotid  on  the  other. 
Since  the  wall  of  the  guttural  pouch  rests  against  the  median 
side  of  the  digastricus  muscle  it  is  opened  by  this  incision. 
The  operator  inserts  an  index  finger  along  the  blade  of  the 
knife  at  first  and  then  withdrawing  the  instrument  passes 
the  other  index  finger  also  in  the  penetrant  wound  and  by 
forcibly  parting  these  dilates  it.  The  abnormal  contents  are 
then  removed  by  means  of  forceps,  curetting  and  irrigation. 
In  order  to  prevent  adhesion  of  the  wound  lips  in  the  firmly 
stretched  stylo-maxillaris  muscle,  introduce  a  strong  drain- 
age tube  into  the  pouch  and  fix  it  to  the  external  borders  of 
the  wound  by  a  suture. 

III.  Dieterich'1  s  method.  This  combines  the  operations 
under  I  and  II,  with  the  difference  that  the  superior  opening 
of  the  pouch  is  made  immediately  behind  the  stylo-maxillaris. 
In  order  to  accomplish  this  the  cutaneous  wound  over  the 
wing  of  the  atlas  must  be  prolonged  below  it.  After  detach- 
ing the  posterior  border  of  the  parotid  gland  the  operator 
searches  in  the  loose  areolar  tissue  with  the  index  finger  of 
the  left  hand  for  the  vascular  angle  which  is  formed  by  the 
occipital,  internal  carotid  and  external  carotid  arteries  which 
may  be  detected  by  pulsation — the  same  is  located  at  a  depth 
of  somewhere  from  8  to  10  cm.  Place  the  volar  surface  of 
the  finger  in  the  vascular  angle  and  push  a  sharp  scalpel 
along  the  dorsal  surface  of  the  finger  to  the  pouch  which 
here  becomes  opened  on  its  posterior  lateral  surface. 

This  method  has  the  advantage  over  Chabert's  that  for 
the  removal  of  hard  contents  (chondroid)  the  opening  can 
be  readily  dilated,  even  to  such  an  extent  that  the  entire 
hand  can  be  passed  into  the  air  sac  and  the  opening  of  the 
Kustachian  tube  be  explored. 


TRACHEOTOMY,  59 


12.     TRACHEOTOMY. 
FIG.  2. 

Instruments.  Razor,  scissors,  convex  scalpel,  tenacula, 
tenactilum  and  ligation  forceps,  trachea  tube,  and  suture  ma- 
terial. 

Technic.  In  the  superior  third  of  the  neck,  in  the  region 
of  the  fourth  to  the  sixth  tracheal  ring,  shave  and  disinfect 
the  skin  on  the  anterior  surface  of  the  neck  to  the  extent  of 
10  cm.  long  by  5  cm.  wide.  The  operation  is  best  performed 
upon  the  standing  animal  with  the  head  extended  In  lat- 
eral decubitis  of  the  horse  the  operation  is  carried  out  with 
some  difficulty,  and  generally  the  operator  fails  to  get  the 
incision  on  the  median  line.  The  operator  stands  before  the 


FIG.  2. 

TRACHEOTOMY,  s,  sterno-thyro-hyoideus  muscle  ;  /,  trachea  ; 
sch,  mucous  membrane  of  the  posterior  wall  of  the  trachea  ; 
/,  interannular  ligament. 

right  shoulder  of  the  horse  and  the  assistant  opposite  him. 
On  the  shaved  area  the  operator  and  his  assistant  takes  up  a 
transverse  fold  of  skin  3  to  4  cm.  high,  and  divides  the  same 
by  an  incision.  The  6  to  8  cm.  long  wound  in  the  skin  then 


6o  TRA  CHEO  TOMY. 

lies  in  the  median  line  of  the  anterior  face  of  the  neck.  Or 
the  incision  may  be  made  by  rendering  the  skin  tense  along 
the  median  line  of  the  trachea  with  the  left  hand,  then  mak- 
ing a  drawing  cut  from  above  to  below  with  the  scalpel. 
After  the  skin  muscle  is  cut  through,  in  order  to  avoid  hem- 
orrhage, separate  the  two  sterno-thyro-hyoideus  muscles  by 
means  of  tenacula  along  the  median  line  in  the  white  strip  of 
connective  tissue.  The  opening  into  the  trachea  may  be 
made  in  a  variety  of  ways.  The  quickest  and  most  crude 
method  is  to  slit  the  trachea  which  has  been  laid  bare  from 
above  downwards  through  three  or  four  tracheal  rings,  and 
pressing  the  severed  ends  apart  insert  the  tube  through  the 
opening.  Since  the  tracheal  rings  are  incomplete,  being 
open  on  their  dorsal  surfaces,  cutting  through  the  ventral 
portion  divides  each  ring  into  two  separate  parts  and  their 
being  pushed  apart,  distorts  them  and  tends  to  the  causation 
of  chondritis  and  collapse  of  the  trachea,  a  danger  which  in- 
creases with  the  duration  of  time  that  the  tube  is  maintained 
in  position.  It  is  therefore  most  suitable  for  hurried  opera- 
tion in  impending  suffocation  where  the  tube  will  probably 
be  needed  for  a  short  time  only. 

A  second  method  of  operation,  illustrated  in  Fig.  2,  con- 
sists in  making  a  transverse  incision  through  the  inter-annu- 
lar ligament  between  the  two  last  exposed  tracheal  rings  the 
length  of  the  diameter  of  the  tube  to  be  inserted.  Make 
a  perpendicular  incision  upward  from  each  end  of  this  at  a 
point  i  to  1.5  cm.  from  the  median  line  through  one  or  two 
tracheal  rings,  according  to  the  size  of  the  tube.  With 
forceps  or  tenaculum  grasp  the  segments  of  partially  de- 
tached cartilage  and  remove  them  by  cutting  through  the 
inter-annular  ligament. 

A  third  and  to  us  preferable  method  is  to  insert  a  scalpel 
transversely  at  about  the  lower  third  of  the  lowermost  bared 
tracheal  ring  and  cutting  outwards  and  upwards  in  a  curved 
line,  pass  through  the  first  inter-annular  ligament  and  con- 
tinue the  incision  into  the  succeeding  tracheal  ring,  curving 


ARYTENECTOMY.  6 1 

the  incision  upward  and  inward  until  the  ring  is  cut  about 
y-$  in  two,  when  the  incision  is  turned  downward  to  eventu- 
ally reach  the  starting  point,  the  isolated  section  of  the  tra- 
chea being  securely  grasped  by  a  pair  of  forceps  before  its 
excision  is  completed.  By  this  method  no  tracheal  ring  is 
severed. 

The  trachea  tube  is  to  be  removed  and  cleansed  daily  as 
long  as  its  use  is  necessary,  and  when  finally  removed  the 
wound  should  be  left  open  and  dressed  antiseptically. 


13.    ARYTENECTOMY. 
PLATE  XI. 

Object.     The  relief  of  roaring  or  laryngismus  paralyticus. 

Instruments.  Razor,  scissors,  scalpel,  razor  shaped 
knife  with  long  handle,  long  curved  sharp  pointed  scissors, 
long  curved  uterine  dressing  forceps,  double  tenaculum  for- 
ceps, trachea  tube,  retractors,  reflecting  lamp,  absorbent  cot- 
ton and  dressing  material. 

Technic.  Secure  the  animal  in  lateral  recumbency 
preferably  upon  the  operating  table  and  induce  complete 
anaesthesia.  Shave  and  disinfect  the  skin  over  the  laryngeal 
region  and  also  over  the  trachea  at  the  usual  point  for 
tracheotomy.  Place  the  animal  upon  its  back  with  the  head 
extended  and  remove  the  halter  or  other  head  gear.  Per- 
form tracheotomy  in  the  manner  described  above,  insert  the 
trachea  tube  and  if  necessary  continue  the  administration  of 
chloroform  through  this  by  means  of  a  funnel  the  small 
end  of  which  is  inserted  in  the  trachea  tube  while  the 
chloroform  is  dropped  on  a  towel  spread  over  the  larger  end. 
The  operator  takes  his  place  on  the  right  side  of  the  animal 
and  the  assistant  on  the  left.  Make  a  longitudinal  incision 
through  the  skin  and  subcutem  beginning  at  the  anterior 
part  of  the  thyroid  cartilage  and  extending  backward  on  the 
median  line  to  the  3rd  or  4th  tracheal  ring.  Control  the 
cutaneous  hemorrhage.  Continue  the  incision  through  the 


PLATE  XI. 
ARYTENECTOMY. 

E,  epiglottis ;  TT,  thyroid  cartilage ;  CC, 
cricoid  cartilage  ;  TRI,  first  tracheal  ring ;  V, 
left  vocal  cord  ;  A,  left  arytenoid  cartilage  sur- 
rounded by  dotted  line  of  incision  ;  CTL,  crico- 
thy-roidean  ligament. 


TR1- 


:    DIVERS/TV  } 


ARYTENECTOMY.  65 

subjacent  muscular  tissue  being  careful  to  follow  the  median 
line  exactly  until  the  crico-thyroidean  ligament,  CTL,  Plate 
XI,  the  cricoid  cartilage  C,  and  the  first  tracheal  ring  TRI, 
are  laid  bare.  Again  control  any  hemorrhage.  Plunge  the 
scalpel  with  its  cutting  edge  directed  backward  through  the 
crico-thyroidean  ligament  on  a  level  with  the  dotted  line  T 
and  extend  this  backward  along  the  median  line  severing  the 
cricoid  cartilage,  C,  and  the  first  tracheal  ring,  TRI.  Insert 
the  retractors  and  have  the  larynx  held  well  open  by  as- 
sistants. Illuminate  the  larynx  by  means  of  a  reflecting 
lamp  as  may  be  required.  After  controlling  any  hemorrhage 
caused  by  the  foregoing  make  an  incision  through  the  mucosa 
and  the  intervening  connective  tissue  between  the  two 
arytenoid  cartilages,  A,  beginning  at  the  anterior  part  and 
extending  backward  to  the  cricoid,  thence  turning  upward 
and  laterally,  incise  the  mucosa  across  the  posterior  end  of  the 
arytenoid  thence  forward  along  its  lateral  border  through 
the  vocal  cord,  V,  and  turning  downward  as  the  animal  lies, 
that  is  toward  the  dorsal  part  of  the  larynx,  continue  the 
incision  to  the  point  of  beginning.  In  making  this  incision 
cut  as  closely  as  possible  to  the  margin  of  the  cartilage  so 
that  a  minimum  amount  of  the  mucous  membrane  will  be 
removed.  Grasp  the  lateral  border  of  the  cartilage  with 
the  long  tenaculum  forceps  and  with  the  razor-shaped  knife 
or  the  scissors  separate  the  lateral  and  anterior  portions  of 
it  from  the  adjacent  tissues  keeping  always  immediately 
against  it  in  order  to  produce  as  clean  a  wound  as  possible 
and  to  avoid  injuring  adjacent  vessels  from  which  hemor- 
rhage would  occur. 

When  the  cartilage  has  been  detached  over  the  greater  part 
of  its  surface  locate  the  crico-arytenoid  articulation  and  dis- 
articulate or  cut  through  the  arytenoid  as  close  to  the  articu- 
lation as  possible  with  the  razor-shaped  knife  or  the  scissors. 
Remove  all  blood  by  means  of  pledgets  of  absorbent  cotton 
securely  held  in  the  long  dressing  forceps,  or  the  clots  may 

5 


66  INTRA-TRACHEAL  IRRIGATION. 

be  pushed  into  the  pharynx  when  they  will  generally  be 
swallowed.  Carefully  remove  any  cartilaginous  remnants 
or  tissue  shreds  and  control  the  hemorrhage  from  any 
visible  vessels.  Dust  the  wounds  thoroughly  with  iodoform 
and  tannin  and  if  the  capillary  hemorrhage  is  great  pack 
the  larynx  with  a  single  strip  of  iodoform  gauze  and  secure 
it  by  sutures  through  the  margin  of  the  skin  wound.  Re- 
move this  tampon  after  twelve  to  twenty-four  hours.  Wash 
and  disinfect  the  laryngeal  wounds  daily.  Remove  and 
cleanse  the  trachea  tube  and  wash  the  tracheal  wound  daily 
and  keep  the  trachea  tube  in  position  for  five  to  seven  days 
according  to  conditions.  After  about  eight  days  the  re- 
tractors should  be  placed  in  the  laryngeal  wound,  the  wound 
dilated  and  the  interior  of  the  larynx  examined  with  the 
aid  of  a  reflecting  lamp  and  any  unhealthy  granulations  or 
other  untoward  conditions  given  proper  attention. 


14.     INTRA-TRACHEAL  IRRIGATION. 

Objects.  The  washing  of  irritant  or  septic  substances 
from,  and  the  disinfection  of,  the  trachea  and  bronchi. 

Instruments.  Same  as  for  tracheotomy,  and  a  gravity 
irrigating  apparatus  fitted  with  3  m.  of  rubber  tubing  about 
i  cm.  in  diameter,  5  liters  of  .6  percent,  soda  bicarbonate  or 
chloride  solution  at  a  temperature  of  37  to  39°  C. 

Technic.  Operate  on  the  standing  animal.  Perform 
tracheotomy.  Elevate  the  gravity  apparatus  containing  the 
irrigating  fluid  i  to  2  m.  above  the  patient,  have  the  animal's 
head  slightly  elevated,  insert  the  free  end  of  the  rubber 
tubing  in  the  trachea  tube  and  let  the  fluid  flow  into  the 
trachea  in  a  moderate  stream  until  it  is  filled  and  the  animal 
makes  expulsive  efforts,  when  the  inflow  is  stopped  and  the 
animal  permitted  to  lower  his  head  and  expel  the  fluid,  then 
raise  the  head  again  and  repeat  until  the  fluid  is  expelled 
clear.  Repeat  the  operation  according  to  requirement.  In 
cases  of  suppurative  bronchitis,  peroxide  of  hydrogen  may 
be  added  to  the  solution. 


INTRA  VENOUS  INJECTION, 


67 


15.     INTRAVENOUS  INJECTION. 
FIG.  3. 

Instruments.     Scissors,  hypodermic  syringe. 

Technic.  The  operation  is  performed  on  the  standing 
animal  on  either  jugular  vein  at  about  the  juncture  of  the 
upper  and  middle  thirds  of  the  neck  ;  to  most  operators  the 
right  jugular  is  the  more  convenient.  At  the  place  desig- 
nated the  subscapulo-hyoideus  muscle  lies  between  the 
jugular  vein  and  the  carotid  artery.  After  clipping  the  hair, 
the  skin  should  be  carefully  disinfected.  The  vein  lies  in 


FIG.  3.     Intravenous  Injection. 

the  jugular  groove  between  the  mastoido-humeralis  and  the 
sterno-maxillaris  muscles  covered  only  by  the  skin  and  skin 
muscle.  Stand  by  the  shoulder  of  the  horse  and  compress 
the  jugular  with  the  thumb  as  shown  in  Figure  3  or  with  the 
second  to  the  fourth  fingers,  in  which  case  the  ball  of  the 
thumb  rests  on  the  mastoido-humeralis  muscle,  in  a  way  that 
the  vein  becomes  filled  above  the  point  of  compression  in  the 


68  INTRA  VENOUS  INJECTION. 

shorn  area  and  stands  out  as  a  swollen  cord.  In  the  case  of 
fleshy  necked  horses  this  compression  is  more  readily  attained 
if  the  head  is  somewhat  elevated  and  extended  by  an 
assistant.  If  the  vein  can  not  be  made  prominent  in  this 
way  the  compression  should  be  alternately  applied  and  with- 
drawn suddenly,  the  course  of  the  vein  then  reveals  itself  by 
a  wave-like  movement  along  the  jugular  groove.  Just  above 
the  point  of  compression  the  vein  is  the  most  fully  distended 
and  firmly  fixed.  After  testing  the  hypodermic  needle  to 
see  that  it  is  open  hold  it  between  the  second  and  third 
fingers  while  the  thumb  covers  its  posterior  opening  and 
thrust  it  through  the  skin,  cutaneous  muscle  and  jugular 
wall,  in  the  direction  of  the  vein  obliquely  forwards  and  up- 
wards i  to  2  cm.  deep,  so  that  the  point  of  the  needle  enters 
the  vessel  at  its  most  distended  part.  In  this  way  it  is  easy 
to  prevent  injury  to  the  median  wall  of  the  vein.  If  the 
vein  has  been  properly  punctured  blood  will  flow  from  the 
needle  upon  the  removal  of  the  thumb.  If  the  vein  is  not 
entered  at  the  first  attempt  the  needle  should  be  partly  with- 
drawn and  then  pushed  in  again  in  a  slightly  different  direc- 
tion. The  compression  is  then  removed  and  the  hypodermic 
syringe  in  which  no  air  is  contained  is  connected  and  the 
contents  slowly  discharged  into  the  vein.  In  withdrawing 
the  needle  be  careful  to  press  the  skin  firmly  against  the 
underlying  part.  The  omission  of  this  precaution  frequently 
results  in  the  formation  of  a  subcutaneous  hematome. 


PHLEBOTOMY.  69 

1 6.     PHLEBOTOMY. 
FIG.  3. 

Instruments.  Razor  or  scissors,  fleams,  lancet,  phle- 
botomy trocar,  spring  lancet,  pins,  suture  material. 

Technic.  a.  Phlebotomy  ivith  fleams  may  be  performed 
on  either  jugular  vein.  The  operation  is  preferably  carried 
out  on  the  standing  animal,  but  is  not  difficult  when  the 
patient  is  recumbent.  The  point  of  operation  is  at  about  the 
boundary  line  between  the  upper  and  middle  cervical  regions, 
because  it  is  here  that  the  subscapulo-hyoideus  muscle  which 
separates  the  jugular  vein  from  the  carotid  artery  is  most 
voluminous  and  consequently  affords  the  greatest  protection 
to  the  latter.  At  this  point  clip  or  shave  and  disinfect  the 
skin.  Grasp  the  extended  blade  of  the  fleam  at  the  joint 
with  the  thumb  and  index  finger  of  one  hand,  while  the 
third  and  fourth  fingers  compress  the  jugular  vein  at  a  point 
far  enough  below  the  shaved  part  that  the  fleam  blade  rests 
upon  it.  In  fleshy-necked  animals  the  course  of  the  vein 
may  be  clearly  made  out  by  causing  its  repeated  distension 
and  relaxation.  It  is  well  to  be  careful  that  the  point  of  the 
fleam  blade  is  not  allowed  to  prick  the  skin  prematurely  and 
render  the  animal  restless,  and  that  the  fleam  blade  is  held 
perpendicular  to  the  surface  and  parallel  to  the  long  axis  of 
the  vein.  The  most  elevated  point  of  the  vein  should  be 
struck  by  the  blade  in  such  a  way  that  the  skin,  subcutane- 
ous muscle  and  jugular  wall  are  penetrated  parallel  to  the 
long  axis  of  the  vessel.  Drive  the  fleam  blade  into  the  vein 
by  a  short,  sharp  blow  with  a  light  wooden  stick.  The  ex- 
tension on  the  fleam  blade  prevents  its  being  driven  too 
deeply.  The  size  of  the  blade  to  be  used  depends  upon  the 
thickness  of  the  skin  and  other  tissues  covering  the  vein.  If 
the  vein  is  opened,  dark  red  bloo^d  escapes  from  the  wound 
in  a  large  stream.  If  the  operation  does  not  succeed  at  the 


70  PHLEBOTOMY. 

first  effort,  one  should  select  an  undamaged  portion  of  the 
skin  for  a  second  attempt  so  that  the  opening  into  the  vein 
ma}'  be  direct  and  clean.  When  the  vein  is  opened  lay  the 
instrument  aside,  the  compression  of  the  vein  being  contin- 
ued in  order  to  prevent  aspiration  of  air  into  it  and  also  that 
the  lips  of  the  wound  shall  not  become  overlapped  by  which 
the  escape  of  blood  would  be  impeded  or  stopped.  The  flow 
of  blood  may  be  favored  by  inducing  masticatory  movements 
by  the  animal.  The  amount  of  blood  withdrawn  varies  be- 
tween 3  and  8  liters,  according  to  the  size  of  the  animal  and 
the  object  to  be  attained.  The  wound  may  be  closed  by  an 
interrupted  or  a  pinned  suture.  For  the  latter,  relieve  the 
compression  on  the  vein  and  grasp  the  lips  of  the  skin  wound 
between  the  finger  and  thumb  and  stick  the  pin  perpendicu- 
larly through  the  middle  of  it  a  few  mm.  from  its  borders. 
Apply  a  noose  of  silk  ligature  previously  prepared  over  the 
pin  and  close  and  tie  the  loop.  In  applying  the  pin  and 
loop,  take  care  not  to  elevate  the  skin  from  the  underlying 
part,  which  tends  to  the  production  of  a  hematonie. 

b.  With  the  lancet  the  operation  is  preferably  performed 
on  the  right  side  of  the  neck.  Compress  the  vein  as  illus- 
trated in  Fig.  3,  and  hold  the  lancet  between  the  thumb  and 
index  finger  with  the  blade  at  right  angles  to  the  handle, 
the  thumb  and  finger  being  so  placed  on  the  blade  that  it 
can  barely  penetrate  the  vein,  and  then  push  it  in  quickly 
just  in  front  of  the  compressing  thumb  through  the  skin, 
subcutem  and  venous  wall  as  deep  as  the  fingers  holding  the 
lancet  will  permit. 

Hold  the  blade  perpendicular  to  the  long  axis  of  the 
vein,  and  avoid  directing  the  point  dorsalwards,  which  would 
endanger  the  superior  wall  of  the  vessel  or  cause  the 
lancet  to  glide  over  the  wall  and  not  enter  the  vein.  When 
the  lancet  has  entered  the  vein  extend  the  wound  somewhat 
toward  the  head  by  flexing  the  hand  dorsally.  In  cattle  it 
is  necessary  to  compress  tte  vein  by  means  of  a  cord  tightly 


LIGATION  OF  THE  CAROTID  ARTERY.  71 

drawn  around  the  neck,  the  operator  taking  the  same  posi- 
tion as  in  the  horse  while  an  assistant  holds  the  animal  by 
the  horns  or  nose.  Close  the  wound  as  in  a. 

Phlebotomy  with  the  spring  lancet  is  carried  out  in  a  sim- 
ilar manner,  the  jugular  being  compressed  in  the  same  way, 
and  the  lancet  with  the  spring  set  placed  over  the  vein  in 
such  a  way  that  the  opening  will  be  made  in  the  same  direc- 
tion and  manner  as  with  the  fleams.  The  lancet  blade  is 
then  released  and  penetrates  the  vein.  The  compression  be- 
low is  continued  as  in  other  cases. 

c.  Phlebotomy  with  the  trocar  is  performed  in  the  same 
manner  as  has  been  described  for  intravenous  injection.  So 
long  as  the  flow  of  blood  continues  the  compression  of  the 
vein  must  not  be  intermitted.  The  phlebotomy  trocar  should 
be  about  5  mm.  in  diameter. 


17.     LIGATION  OF  THE  CAROTID  ARTERY. 
XII. 


Objects.  The  control  of  hemorrhage  from  wounds  or 
the  prevention  of  hemorrhage  during  the  removal  of  tumors 
or  other  operations  in  the  parotid  region. 

Instruments.  Scissors,  scalpel,  tenacula,  aneurism 
needle,  mouse-toothed  forceps,  ligation  forceps,  suture 
material. 

Technic.  The  operation  is  possible  on  the  standing 
animal  with  the  aid  of  cocaine  or  other  local  anaesthetic  but 
it  is  preferable  to  confine  the  patient  in  lateral  recumbency 
and  anaesthetize. 

The  operation  is  made  at  the  same  point  as  for  phlebotomy 
and  the  same  cutaneous  wound,  a,  Plate  XII,  may  be  used 
for  this  purpose.  The  incision  should  be  at  least  10  cm. 
long  extending  through  the  skin,  fleshy  panniculus  and 


PLATE  XII. 

FIG.  i. — a,  Ligation  of  the  common 
carotid  artery  ;  b,  CEsophagotomy. 

FIG.  2. — Ligation  of  the  common 
carotid  artery.  c,  common  carotid 
artery  ; /,  jugular  vein  ;  v, vagus  nerve  ; 
s,  sympathetic  nerve ;  r,  recurrent 
nerve ;  p,  cervical  panniculous  car- 
nosus  muscle ;  m,  sternomaxillaris 
muscle  ;  st,  levator  humeri  muscle. 

FIG.  3. — CEsophagotomy.  c,  com- 
mon carotid  artery  ;  /,  jugular  vein  ; 
o,  of,  oesophagus ;  s,  sympathetic 
nerve  ;  /,  trachea  ;  st,  mastoido  hum- 
eralis  (lavator  humeri)  muscle. 


FIG   i. 


FIG.  3. 


LIGATION  OF  THE  CAROTID  ARTERY.  75 

subscapulo-hyoideus  muscles  and  then  force  a  passage  with 
the  fingers,  with  the  cautious  aid  of  the  knife,  to  the  trachea. 
At  the  region  of  the  neck  indicated,  the  carotid  passes  along 
the  border  between  the  lateral  and  dorsal  surfaces  of  the 
trachea,  accompanied  dorsally  by  the  vagus  and  sympathetic 
nerves  and  ventrally  by  the  recurrent.  In  Figure  2,  Plate  XII 
the  vagus  and  sympathetic  nerves,  v  and  a,  are  pushed  out 
of  their  normal  position  and  appear  ventrally  to  the  carotid. 
Pass  the  index  finger  over  and  behind  the  carotid  until  the 
trachea  is  reached,  and  encircling  the  inner  and  lower  sides 
of  the  artery,  force  a  way  through  the  surrounding  areolar 
tissue  and  draw  the  vessel  out  through  the  operation  wound. 
As  a  rule  the  carotid  is  still  surrounded  by  the  lamellar 
fascia,  which  comes  from  the  deep  fascia  of  the  neck  in 
which  also  the  three  above  mentioned  nerves  are  found. 
These  nerves  must  be  carefully  separated  from  the  carotid 
and  must  on  no  account  be  included  in  the  ligature.  Ligate 
the  carotid  twice  with  an  interval  of  about  2  cm.  between 
the  two  ligatures  and  divide  the  artery  midway  between  the 
two.  The  second  ligature  is  necessary  in  order  to  prevent 
hemorrhage  from  the  distal  end  through  collateral  anasto- 
moses and  it  is  essential  to  sever  the  artery  in  order  to  avoid 
its  rupture  by  the  stretching  of  the  undivided  carotid  dur- 
ing movements  of  the  neck  where  the  nutrition  has  been  cut 
off  at  the  point  of  ligation.  Provide  drainage  for  the  wound 
and  suture  the  muscle  and  skin. 


(ESOPHAGOTOMY. 


i8.     CESOPHAGOTOMY. 
PLATE  XII. 

Instruments.  Razor,  scissors,  convex  scalpel,  straight 
probe-pointed  bistoury,  tenacula,  artery  forceps,  absorbent 
cotton,  suture  material. 

Technic.  The  operation  can  be  carried  out  on  the  stand- 
ing or  the  recumbent  animal.  At  its  origin  the  oesophagus 
lies  above  the  trachea,  generally  somewhat  to  the  left  of  the 
median  line  and  gradually  deviates  farther  to  the  left  until 
toward  the  lower  cervical  region  it  lies  down  along  the  left 
side  of  the  trachea. 

The  operation  is  performed  at  any  point  between  the 
pharynx  and  chest  where  the  lodgment  of  a  foreign  body  or 
other  condition  may  demand  it.  When  the  oesophagus  is 
empty  the  operation  is  best  performed  in  the  lower  third  of 
the  neck  at  b,  Figure  i,  Plate  XII. 

An  incision  10  cm.  long  through  the  skin  and  skin  muscle 
is  made  on  the  left  side  between  the  anterior  border  of  the 
mastoido-humeralis  muscle  and  the  jugular  vein.  With  one 
finger  each  of  the  left  and  right  hand  divide  the  loose  con- 
nective tissue  down  to  the  oesophagus,  which  lies  between 
the  left  scalenus  muscle,  trachea  and  the  jugular  vein. 
Along  the  supero-external  border  of  the  trachea  runs  the 
carotid,  accompanied  dorsally  by  the  vagus  and  sympathetic 
and  ventrally  by  the  recurrent  nerves.  The  oesophagus  feels 
like  a  round  muscle  within  which  one  can  feel  a  firmer  cord, 
the  mucous  membrane,  and  has  a  pale  red  color.  (Esopha- 
gus and  trachea  are  surrounded  by  the  deep  fascia  of  the 
neck.  Pass  one  finger  around  the  oesophagus  from  behind, 
draw  it  away  from  the  trachea,  force  a  passage  through  the 
deep  fascia  of  the  neck  and  draw  the  oesophagus  out  through 
the  external  wound.  After  making  an  incision  through  the 
muscle  and  mucous  membrane  introduce  a  probe  pointed 


(ESOPHAGOTOMY.  77 

scalpel  or  a  scissors  blade  into  the  lumen  of  the  oesophagus 
and  split  its  wall.  The  mucous  membrane  is  white  and  lies 
in  thick  longitudinal  folds.  When  there  is  a  foreign  body 
in  the  oesophagus  the  operation  is  performed  at  the  point 
where  it  is  lodged  in  the  manner  described  and  the  incision 
should  be  made  only  large  enough  to  permit  its  removal.  In 
diverticuli  of  the  oesophagus  an  elliptical  piece  of  the  mucous 
membrane  which  has  been  overstretched  is  cut  out.  The 
cesophageal  wound  is  closed  by  a  laminated  suture,  that  is, 
the  mucous  membrane  is  united  by  means  of  an  intestinal 
suture  and  the  muscular  wall  closed  over  this.  The  skin 
and  muscular  wound  may  either  be  left  open  or  closed  with 
the  Bayer  suture  and  bandaged  with  a  drainage  tube  in  the 
lower  angle  of  the  wound. 


78  PUNCTURE  OF  THE  CHEST. 

III.     OPERATIONS  ON  THE  TRUNK  AND  GENITAL 
ORGANS. 

19.     PUNCTURE  OF  THE  CHEST. 
FIG.  4. 

Objects.    The  relief  of  hydrothorax  or  pyothorax. 

Instruments.  Razor,  scissors,  trocar,  i  m.  of  rubber 
tubing  of  the  same  size  as  the  trocar,  vessel  for  receiving 
the  escaping  fluid,  dressing  material. 

Technic.  Operate  upon  the  standing  animal,  the  point 
of  operation  being  the  seventh  intercostal  space  on  the  left 
side,  and  the  sixth  on  the  right.  Dogs  may  be  laid  upon 


FIG.  4. 
Puncture  of  the  chest  ;  puncture  of  the  intestine. 

the  table.  The  ribs  are  enumerated  from  behind  forward, 
counting  eighteen  for  the  horse  and  fourteen  for  the  dog. 
Clip  or  shave  the  designated  intercostal  area  immediately 
above  the  thoracic  vein.  Grasp  the  trocar  firmly  with  the 


PUNCTURE  OF  THE  INTESTINES.       79 

thumb  and  index  finger  of  one  hand  at  a  distance  from  the 
point  which  will  permit  the  canula  to  enter  the  chest.  Af- 
ter the  skin  over  the  seat  of  operation  has  been  drawn  aside 
by  the  hand  place  the  trocar  at  the  anterior  border  of  the 
rib  with  the  point  inclined  slightly  forward  and  with  a  sharp 
blow  with  the  palm  of  the  other  hand  drive  the  instrument 
through  the  skin,  skin  muscle,  intercostal  muscles,  internal 
thoracic  fascia  and  pleura  into  the  pleural  sac.  When  the 
resistance  ceases,  the  thoracic  cavity  has  been  entered.  Re- 
move the  stilette  and  permit  the  pus,  lymph,  or  other  fluid 
to  escape.  This  escape  is  at  first  continuous,  but  later  be- 
comes rythmic,  synchronous  with  respiration.  The  inter- 
mission of  the  outflow  during  inspiration  permits  air  to  enter 
the  pleural  cavity  unless  precautions  are  taken  against  it  ; 
this  is  most  readily  obviated  by  slipping  one  end  of  the  rub- 
ber tubing  over  the  exposed  end  of  the  canula  and  placing 
the  other  extremity  in  the  receptacle  for  the  fluid  where  it 
will  be  submerged.  This  will  not  only  prevent  aspiration  of 
air  into  the  chest  but  will  act  as  a  syphon  to  aid  in  the  aspi- 
ration of  the  fluid  from  the  pleural  cavity.  In  the  absence 
of  the  tubing  the  entrance  of  air  may  be  avoided  by  closing 
the  canula  with  the  finger  after  each  expiration. 


20      PUNCTURE  OF  THE  INTESTINES 
FIGS.  4,  5. 

Object.     The  relief  of  intestinal  tympany. 

Instruments.     Razor,  scissors,  trocar,  disinfectants. 

Technic.  Puncture  of  the  intestine  is  preferably  per- 
formed on  the  standing  horse  but  may  be  carried  out  on  the 
recumbent  animal.  The  point  of  operation  is  in  the  right 
flank  about  equi-distant  from  the  last  rib,  the  extremities  of 
the  transverse  processes  of  the  lumbar  vertebrae  and  the  ex- 
ternal angle  of  the  ilium  in  the  standing  horse,  at  the  upper- 
most point  of  the  abdomen  in  the  recumbent  animal,  that  is, 


8o  PUNCTURE  OF  THE  INTESTINES. 

at  the  most  prominent  part  of  the  distension.  After  the 
skin  at  this  place  has  been  clipped  or  shaved  and  disinfected 
grasp  the  trocar  with  the  index  finger  and  the  thumb  of  the 
left  hand  and  holding  the  instrument  perpendicular  to  the 
skin,  give  it  a  firm  quick  blow  with  the  palm  of  the  right 
hand  and  drive  it  through  the  abdominal  walls  into  the 
intestine.  With  a  properly  constructed  trocar  of  the  dimen- 
sions suggested  in  Figure  5  no  preliminary  puncture  with 
the  lancet  is  required  or  advisable.  The  cutting  end  of  the 
stilette  should  be  very  long,  tapering  and  sharp  so  that  it 
will  cut  as  freely  as  the  lancet.  By  performing  the  opera- 
tion as  directed  the  trocar  ordinarily  punctures  the  caecum. 


FIG.  5. 

Intestine  trocar  with  sheath.     Outside  diameter  of  canula  3  mm  , 
length  of  canula,  16  cm. 

Withdraw  the  stilette  and  permit  the  gas  to  escape  through 
the  canula.  The  canula  may  become  occluded  by  particles 
of  ingesta  entering  it  and  these  should  be  removed  by  rein- 
serting the  stilette.  The  intestine  first  punctured  may 
collapse  and  the  flow  of  gas  cease  while  the  tympany  con- 
tinues in  other  parts  ;  this  may  be  overcome  by  reintroducing 
the  stilette  and  pushing  the  trocar  through  the  distal  wall  of 
the  bowel  and  into  the  next  section  of  intestine  beyond. 
If  this  does  not  succeed  the  trocar  may  be  withdrawn  and 
reinserted  in  a  neighboring  area  or  if  need  be  on  the  opposite 
side  of  the  .animal.  In  withdrawing  the  canula  replace  the 
stilette  and  press  the  skin  against  the  abdominal  with  the 
thumb  and  finger  of  one  hand  while  the  trocar  is  drawn  out 
with  the  other.  This  tends  to  prevent  particles  of  ingesta 


SUBCUTANEOUS  CAUDAL  MYOTOMY.  81 

from  following  the  canula  out  of  the  intestine  and  becoming 
lodged  at  some  point  in  the  track  of  the  wound  to  set 
up  inflammatory  processes  there.  Before  introduction,  the 
trocar  should  always  be  rendered  sterile  but  should  not  bear 
irritant  antiseptics,  which  becoming  lodged  in  the  wound 
tend  to  irritate  the  tissues  and  produce  abcesses.  Puncture 
of  the  intestine  is  so  often  extremely  urgent  that  deliberate 
aseptic  precautions  are  not  always  practicable  and  trocariza- 
tion  only  too  frequently  results  in  abscesses  in  the  abdominal 
wall.  Its  prevention  must  depend  chiefly  upon  the  disinfec- 
tion of  the  skin  and  instrument.  It  becomes  important  to 
use  an  instrument  which  is  clean  in  advance.  If  the  one 
shown  in  fig.  5  is  well  disinfected  after  using  and  the  sheath 
is  filled  with  alcohol  before  it  is  screwed  on,  the  instrument 
will  remain  sterile  until  it  is  again  unsheathed  and  then  the 
alcohol  will  quickly  evaporate  and  leave  it  aseptic. 


21.     SUBCUTANEOUS  CAUDAL  MYOTOMY. 
FIG.  6. 

Object.     The  correction  of  curved  tail. 

Instruments.     Sharp  straight  tenotome,  bandage. 

Technic.  The  point  or  points  of  curvature  and  their 
extent  are  to  be  carefully  noted  by  having  the  animal  trotted 
away  from  the  operator.  The  curvature  is  generally  due  to 
unequal  development  of  the  two  levator  or  extensor  muscles 
Fig.  6  e,  though  quite  rarely  the  depressors,  /,  may  be 
implicated.  Confine  the  animal  in  stocks,  or  in  default  of 
these,  control  by  means  of  a  twitch  and  sideline.  Cleanse 
and  disinfect  the  tail  and  have  it  sharpty  bent  by  an  assist- 
ant in  the  opposite  direction  to  the  curvature.  Locate  the 
longitudinal  furrow  between  the  levator  and  depressor  mus- 
cles on  the  convex  side  and  at  the  lower  margin  of  the 
levator  and  just  above  v,  Fig.  6,  insert  the  tenotome  at  the 
6 


82 


SUBCUTANEOUS  CAUDAL  MYOTOMY. 


most  prominent  part  of  curvation,  the  incision  being  parallel 
with  the  muscular  fibers,  and  push  the  instrument  entirely 
through  the  muscle  to  the  vertebra,  then  turning  the  cutting 
edge  upwards,  at  the  same  time  advancing  the  point  of  the 
tenotome  toward  the  median  line,  sever  the  entire  muscle. 
The  superior  lateral  caudal  artery,  s,  Fig.  6,  bleeds  profusely 
if  severed,  and  wounding  of  it  may  usually  be  avoided  by 
withdrawing  the  tenotome  a  trifle  in  passing  that  point. 
Wounding  the  skin  over  the  muscular  incision  is  avoided  by 


FIG.  6. 

Transverse  section  of  the  tail,  n,  caudal  vertebra  ;  c,  sacro- 
coccygeus  lateralis  muscle  ;  £,  sacro-coccygeus  superior  ;  f, 
depressor  longus  and  brevis  muscles  (sacro-coccygeus  infer- 
ior) ;  z,  intertransversales  muscles  ;  a,  coccygeal  artery  ;  s,  su- 
pero-lateral  coccygeal  artery  ;  /,  infero-lateral  coccygeal  ar- 
tery ;  v,  caudal  veins  (dorsal,  ventral,  lateral)  ;  sch,  caudal 
fascia  ;  h,  skin. 

placing  the  thumb  of  the  left  hand  over  the  line  of  incision 
so  the  knife  will  be  recognized  as  soon  as  the  muscle  and 
caudal  fascia  are -cut  through.  Remove  the  knife  in  the  same 
manner  as  introduced.  Release  the  horse  and  have  him 
trotted  agai n .  If  the  operation  is  sufficient  the  tail  should  curve 
in  about  the  same  degree  as  before,  but  in  the  opposite  direc- 


CAUDAL  MYECTOMY.  83 

tion.  If  this  has  not  been  attained  examine  carefully  and 
sever  any  remaining  bundles  of  muscle,  and  this  not  sufficing 
repeat  the  operation  as  before  at  another  point  5  or  6  cm. 
above  or  below  the  first,  severing  the  muscle  again.  Or  if 
the  depressor  appears  implicated,  sever  it  in  a  similar  manner. 
In  extreme  cases  the  entire  lateral  half  of  muscles,  tendons 
and  aponeurosis  may  be  severed.  Apply  an  antiseptic  pad 
to  the  wound  and  retain  it  by  a  moderately  firm  bandage, 
which  serves  at  once  as  an  occlusive  dressing  and  effective 
hemostatic.  Remove  the  bandage  after  24  hours. 


22.     CAUDAL  MYECTOMY. 
FIG.  6  and  PLATE  XIII. 

Objects.  For  the  prevention  of  the  gripping  of  the  reins 
by  the  tail. 

Instruments.  Elastic  bandage,  elastic  ligature,  straight 
bistoury,  tenacula,  absorbent  cotton,  bandages,  disinfecting 
material. 

Technic.  Confine  the  animal  in  lateral  decubitis  or  in 
stocks,  cleanse  and  disinfect  the  tail,  apply  the  elastic  bandage 
tightly  to  it  beginning  at  the  apex  and  continuing  to  its 
base  and  then  apply  the  elastic  ligature  as  close  as  possible 
to  the  root  of  the  tail.  Have  an  assistant  hold  the  tail  up- 
wards, i.e.,  dorsalwards,  and  tightly  stretched.  Make  an 
incision  15  to  20  cm.  long,  over  the  middle  of  the  inferior 
surface  of  each  depressor  longus  muscle,  beginning  close 
against  the  elastic  ligature  and  extending  toward  the  apex, 
severing  at  once  the  skin  and  caudal  fascia  down  to  the 
muscle.  Let  an  assistant  retract  the  lips  of  the  incision  with 
tenacula  while  the  operator  dissects  the  depressor  longus 
muscle,  DC,  Plate  XIII,  from  the  adjacent  tissues  at  either 
side,  sever  it  by  a  transverse  incision  close  against  the  liga- 


Pl,ATE  XIII. 

CAUDAI,  MYECTOMY  To  PREVENT  GRIPPING  OF 
THE  REINS. 

DC,  Depressor  coccygeus  longus  muscle  ;  T, 
tourniquet. 


CAUDAL  MYECTOMY.  87 

tare  and  dissect  away  the  entire  muscle  down  to  the  lower 
end  of  the  wound  and  there  excise  it.  The  small  depressor 
brevis,  lying  on  the  median  side  of  the  longus  need  not  be 
removed,  thus  preserving  a  limited  depressor  power.  Re- 
peat the  operation  on  the  opposite  depressor.  Make  two 
elongated  tampons  of  absorbent  cotton,  of  the  size  and  form 
of  the  muscles  removed,  saturate  these  in  1-1000  sublimate 
solution,  insert  neatly  in  the  wounds  and  apply  a  moderately 
firm  bandage  as  closely  as  possible  to  the  elastic  ligature. 
Remove  the  ligature,  upon  which  hemorrhage  ensues,  which 
is  to  be  controlled  by  the  application  of  a  second  bandage 
extending  higher  up  on  the  tail  over  the  previous  location 
of  the  elastic  ligature.  Remove  the  bandage  in  24  hours, 
wash  the  parts  and  saturate  the  tampons  again  with  i-iooo 
sublimate  solution  and  apply  a  fresh  bandage,  allow  it  to  re- 
main for  another  24  hours,  remove  the  bandage  and  tampons 
and  treat  as  an  open  wound.  Care  should  be  taken  to  not 
apply  the  bandage  too  tightly  or  leave  it  in  place  for  more 
than  24  hours,  since  otherwise  necrosis  of  the  tail  is  liable 
to  occur  and  necessitate  amputation. 


88 


AMPUTATION  OF  THE  TAIL. 


23.     AMPUTATION  OF  THE  TAIL. 
FIG.  6  AND  7. 

Objects.     Malignant  or  incurable  diseases  of  the  tail. 

Instruments.  Docking  shears,  ring  cautery  iron,  dock- 
ing chisel,  mallet,  a  block  of  wood,  suture  material. 

Technic.  I.  Docking  with  the  shears.  Operate  on  the 
standing  animal  secured  in  the  stocks  or  with  the  aid  of  the 
twitch  and  one  fore  foot  held  up  or  the  side  line  applied  to 


FIG.  7. 

Amputation  of  the  tail.     /,  ligature  for  binding  the  hair  of 
the  tail  upwards. 

a  hind  foot.  The  point  of  amputation  is  determined  by  the 
location  of  the  disease.  At  this  point  the  hair  is  parted 
around  the  organ,  turned  upwards  and  bandaged  to  the  root  of 
the  tail  with  a  compression  bandage  which  at  the  same  time 
serves  to  retain  the  hair  out  of  the  operator's  way  and  to 
make  the  operation  bloodless.  Beneath  the  part  clip  the 


AMPUTATION  OF  THE  TAIL.  89 

hair  away  for  a  space  of  3  to  4  cm.  around  the  tail,  have  an 
assistant  hold  it  horizontally,  stand  at  the  side,  behind  the 
left  leg  and  apply  the  docking  shears  in  such  a  way  that  the 
clipped  portion  of  the  dock  rests  in  the  semi-circular  depres- 
sion in  the  shears.  By  quick  and  powerful  closing  of  the 
handles  of  the  docking  shears  cut,  if  possible,  between  two 
caudal  vertebrae  at  one  stroke  through  the  entire  organ. 
Grasp  the  stump  of  the  tail  with  the  left  hand  and  press  the 
red-hot  ring  iron  against  the  parts  between  the  skin  and 
vertebrae  for  from  ten  to  twenty  seconds  in  order  to  stop  the 
hemorrhage  so  that  a  dry  and  firm  necrotic  scab  covers  the 
wound  surface.  In  cattle  and  dogs  the  tail  is  amputated  in 
a  similar  manner  between  two  vertebrae  ;  a  straight  knife 
will  answer  for  operating  instrument.  Hemorrhage  is  like- 
wise most  promptly  controlled  by  cautery.  legating  the 
arteries  and  applying  a  bandage  is  more  aesthetic. 

II.  Amputation  with  the  chisel.  Prepare  for  the  operation 
in  the  same  manner  as  in  I.  Have  an  assistant  hold  a  block 
of  wood  against  the  ventral  surface  of  the  tail  at  the  point 
for  amputation.  Place  the  chisel  on  the  dorsal  surface  of 
the  tail  at  the  point  desired,  with  its  convex  side  directed 
towards  the  base  of  the  organ,  and  with  a  vigorous  blow 
with  the  mallet  drive  the  chisel  through  it  against  the 
wooden  block  held  below.  In  cases  of  extensive  melanosis 
the  chisel  may  be  far  too  narrow  to  cut  off  the  entire  organ 
at  one  blow  in  which  case  the  instrument  is  still  to  be  placed 
centrally  and  driven  through  the  caudal  vertebrae  and  the 
lateral  parts  may  then  be  severed  with  a  scalpel.  There  is 
now  left  a  triangular  wound,  the  vertebra  constituting  the 
apex.  Ligate  any  visible  vessels  and  draw  the  lateral  flaps 
together  on  the  median  line  by  means  of  strong  silk  sutures 
passed  through  the  two  flaps  at  their  thickest  parts  and 
unite  the  edges  of  the  wound  by  frequent  interrupted  sutures. 
Apply  antiseptics  and  remove  the  bandage.  This  operation 
is  preferable  in  point  of  blemish  and  sensibility  of  the  stump 
to  I. 


90  URETHROTOMY.     LITHOTOMY. 

24.     URETHROTOMY.     LITHOTOMY. 
FIG.  8,  9. 

Objects.  For  the  removal  of  calculi  from  the  bladder  or 
urethra  or  performing  other  operations  on  these  parts. 

Instruments.  Catheter,  convex  scalpel,  scissors,  artery 
and  compression  forceps,  tenacula,  litliotome,  lithotomy 
forceps,  lithotrite,  absorbent  cotton,  drainage  tube,  suture 
material. 

Technic.  Urethrotomy  may  be  performed  on  horses  in 
a  standing  position,  the  hind  feet  being  secured  with  hobbles. 

It  is  best,  however,  to  operate  under  anaesthesia  with  the 
patient  in  lateral  or  dorsal  recumbency,  either  on  the  operat- 
ing table  or  cast,  being  careful  to  secure  as  gently  as  possible, 
having  first  emptied  the  bladder  if  practicable,  since  rupture 
of  anfoverdistended  viscus  may  readily  occur  during  violent 
struggles  by  the  animal. 

The  point  of  operation  will  depend  upon  the  location  of 
the  calculus  or  other  obstacle.  If  it  is  found  in  the  pelvic 
portion  of  the  uiethra  or  in  the  bladder,  the  operation  is 
made  at  the  ischial  notch,  Fig.  8.  First  the  penis  is  drawn 
out  from  the  prepuce  and  the  catheter  introduced  into  the 
urethra  and  pushed  upward  until  it  has  passed  the  ischial 
notch.  After  disinfection  of  the  skin,  render  it  tense  and 
make  a  5  cm.  long  incision  on  the  median  line  at  the  ischial 
arch  through  the  skin,  bulbo-cavernosus  muscle,  spongy 
portion  of  the  urethra,  and  the  urethral  mucous  membrane 
down  to  the  catheter,  Fig.  9,  k.  In  order  to  prevent  infiltra- 
tion of  urine  after  the  operation,  special  care  is  to  be  taken 
to  make  the  lower  end  of  the  wound  slanting  in  such  a 
manner  that  the  inner  margin  is  higher  than  the  outer. 

After  the  catheter  has  been  drawn  back  away  from  the 
ischial  arch,  introduce  the  lithotomy  forceps  into  the  urethra 
or  bladder,  grasp  the  stone  and  draw  it  outward  in  its  natural 
direction.  The  grasping  of  the  stone  by  the  forceps  is 
materially  aided  by  means  of  the  left  hand  introduced  into 


URETHROTOMY.     LITHOTOMY.  91 

the  rectum.  One  must  avoid  grasping,  along  with  the  stone, 
the  mucous  membrane  of  the  bladder.  Partial  rilling  of  the 
bladder  with  a  tepid  aseptic  solution  will  aid  in  grasping  the 
calculus  and  in  avoiding  the  implication  of  the  bladder  walls. 
By  careful  rotary  movement  and  pushing  the  forceps  back- 
ward and  forward  the  operator  can  determine  before  the  ex- 
traction of  the  stone  if  the  forceps  can  be  withdrawn  easily 
and  without  much  resistance  through  the  neck  of  the 


FIG.  8.     Urethrotomy  at  the  ischial  notch. 

bladder.  If  the  stone  is  so  large  that  it  can  not  pass  the 
neck  of  the  bladder  lithotripsy  must  be  performed.  This 
operation  requires  time  and  patience,  since  as  a  rule  it  is  not 
possible  to  encompass  the  entire  calculus  with  the  forceps. 
That  is,  the  narrowness  of  the  neck  of  the  bladder  prevents 
the  sufficiently  wide  opening  of  the  forceps.  The  stone  con- 
sequently must  be  gradually  broken  off  at  its  periphery  and 
the  individual  pieces  of  calculus  removed.  The  character  of 
the  surface  of  the  stone  has  an  evident  bearing  upon  the 
practicability  of  lithotripsy. 

When  this  operation  is  impossible,  the  operative  dilation 


92 


URETHROTOMY.     LITHOTOMY. 


of  the  neck  of  the  bladder  with  the  lithotome  can  be  under- 
taken as  a  last  resort.  Introduce  the  instrument  closed  into 
the  bladder,  it  is  then  opened  and  the  neck  of  the  bladder 
divided  upward  and  laterally  as  the  instrument  is  withdrawn. 
In  order  to  prevent  injury  to  the  rectum  it  should  be  emptied 
before  the  operation  is  undertaken.  After  the  removal  of 
the  stone,  push  the  catheter  again  over  the  ischial  arch  and 
unite  the  lips  of  the  wound  in  the  urethral  mucous  mem- 


FiG.  9.  Urethrotomy  (life  size),  h,  skin  ;  a,  retractor  penis  muscle  ; 
b,  bulbo-cavernous  muscle  ;  c,  spongy  urethra  ;  u,  urethra  ;  k, 
catheter. 

brane  b}^  means  of  intestinal  sutures.  Flush  the  bladder  or 
urethra  by  means  of  a  warm  3  per  cent,  boric  acid  solution 
injected  through  the  catheter  and  then  withdraw  the  latter. 
Finally,  suture  the  skin  wound  and  insert  a  drainage  tube 
or  iodoform  gauze  in  the  lower  angle  of  the  wound.  The 
whole  wound  may  be  left  entirely  open  and  be  dressed  daily 
with  antiseptics.  For  student  practice,  on  an  anaesthetized 
horse,  introduce  a  stone  into  the  bladder  through  the  ure- 
thral wound  and  practice  grasping  and  removing  it  with  the 
lithotomy  forceps. 


AMPUTATION  OF  THE  PENIS.  93 

25.     AMPUTATION  OF  THE  PENIS. 
XIV. 


Instruments.  Scalpel,  elastic  ligature,  strong  silk 
thread,  strong  piece  of  tape  i  m.  long,  artery  and  compres- 
sion forceps. 

Technic.  The  operation  is  carried  out  on  the  recumbent 
animal  under  complete  anaesthesia,  the  upper  hind  foot  be- 
ing drawn  forward  or  otherwise  so  fixed  as  to  not  obstruct 
the  field  of  operation.  The  point  of  operation  is  determined 
by  the  character  of  the  disease  and  the  object  to  be  attained. 
It  may  be  made  at  any  point  from  the  glans  penis  to  the 
attachment  of  the  corpus  cavernosum  to  the  ischium.  If 
possible  amputate  in  front  of  the  preputial  ring.  After  the 
penis  is  drawn  out,  and  the  preputial  region  is  carefully 
cleansed  with  brush  and  soap,  an  assistant  grasps  it  just  be- 
hind the  preputial  ring  with  the  hand  and  holds  it  firmly. 
A  temporary  elastic  ligature,  p,  is  then  applied  in  front  of  the 
hand  around  the  penis,  or  the  piece  of  tape  is  looped  around 
it  above  the  hand  and  it  is  made  to  serve  both  as  a  tour- 
niquet and  as  a  means  for  holding  the  penis,  and  it  is  then 
excised  by  a  circular  incision  about  5  cm.  in  front  of  the 
elastic  ligature,  or  immediately  in  front  of  the  preputial 
ring.  The  dorsal  blood  vessels  of  the  penis  are  ligated  sep- 
arately. The  urethra,  u,  lying  on  the  ventral  side  of  the 
penis,  covered  by  the  corpus  cavernosum  of  the  urethra,  is 
dissected  out  of  the  urethral  groove  for  a  distance  of  about 
2  cm.,  its  dorsal  wall  slit  and  the  mucous  membrane  sutured, 
spread  out  fan-like  to  the  surrounding  tissues.  The  urethra 
can  also  be  slit  dorsally  and  ventrally  and  the  halves  sutured 
to  the  left  and  the  right.  A  silk  ligature,  //,  is  applied  to  the 
corpus  cavernosum,  c,  just  above  the  point  of  excision  of  the 
penis  and  the  elastic  ligature  then  removed.  After  a  few 
days  the  silk  ligature  is  also  removed. 


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VAGINAL  OVARIOTOMY  IN  THE  MARE.          97 
26.     VAGINAL  OVARIOTOMY  IN  THE  MARE. 

FlGS.    10,  II   AND   Pl,ATE  XV. 

Objects.  The  alleviation  of  vice  when  related  to  ovarian 
irritation  or  disease. 

Instruments.  Colin's  scalpel,  ratchet  ecraseur,  55  cm. 
long. 

Technic.  The  vnlvo-vaginal  canal  of  the  mare  is  unique 
in  its  physiological  behavior.  Under  venereal  excitement  or 
the  introduction  of  the  operator's  hand  or  of  tepid  water  the 
organ  has  the  power  of  "  ballooning  "  or  dilating  to  a  degree 
not  seen  so  far  as  we  know  in  other  animals ;  the  walls  be- 
come erected,  hard,  and  stand  apart  from  each  other,  filling 
the  pelvic  cavit}^,  the  vaginal  walls  resting  firmly  against  the 


FIG.  10.     Special  spraying  ecraser,  55  cm.  long. 


FIG.  ii.     Colin's  scalpel. 

pelvic  bones  at  every  part  except  at  the  points  where  the  blad- 
der and  rectum  intervene  and  these  organs  are  pressed  out  flat 
and  occupy  a  minimum  space.  In  the  quiescent  state  the 
vaginal  walls  are  in  contact  and  from  the  perinaeum  forward 
to  within  about  locm.  of  the  uterine  os,  the  vulva  and  vagina 
are  connected  above  with  the  rectum  by  the  pelvic  connec- 
tive tissue,  while  anterior  to  this  point  the  vagina  is  covered 
by  peritoneum,  and  it  is  in  this  area  that  the  incision  needs 
7 


PLATE  XV. 
VAGINAL  OVARIOTOMY  IN  THE  MARE. 

Diagrammatic  sagittal  section  through  the 
"ballooned  "  vagina.  V,  vagina  ;  OA,  operative 
area  ;  I,  point  of  incision  ;  U,  uterus  ;  R,  rectum  ; 
A,  aorta  with  dotted  lines  posteriorly  to  indi- 
cate location  of  the  iliacs. 


VAGINAL  OVARIOTOMY  IN  THE  MARE.         101 

be  made  in  the  operation.  The  ballooning  of  the  vagina 
profoundly  alters  the  relation  of  this  operative  area,  OA, 
Plate  XV,  and  changes  it  from  the  horizontal  in  the  quies- 
cent organ  to  the  perpendicular  in  the  ballooned  conditioned. 
These  variations  permit  two  methods  of  operation,  on  the 
quiescent  organ  where  the  incision  must  be  upwards,  and  on 
the  "  ballooned  "  or  erected,  where  it  must  be  directed  for- 
wards. We  follow  the  latter,  because  since  the  "balloon- 
ing "  can  always  be  induced,  the  operation  can  thus  be  made 
uniform  in  all  cases,  and  we  believe  it  safer  and  more  readily 
performed.  The  operation  should  always  be  performed  on 
the  standing  animal,  and  stocks  constitute  the  proper  form 
of  restraint.  It  can  be  performed  under  other  means  of  re- 
straint, even  in  the  recumbent  animal,  but  it  is  inadvisable 
and  greatly  increases  the  difficulties  and  dangers.  Secure 
in  the  stocks  with  the  head  elevated,  a  rope  over  the  back  to 
prevent  rearing,  straps  beneath  the  body  to  prevent  lying 
down,  straps  or  ropes  before  and  behind  the  animal  to  pre- 
vent backward  and  forward  movements,  all  four  feet  pinioned 
to  the  floor,  and  the  tail  firmly  secured  and  stretched  to  a 
beam  above. 

With  soap,  water  and  brush  cleanse  the  tail,  perineum  and 
vulva  thoroughly,  being  especially  careful  to  remove  all 
detachable  masses  of  sebum  ;  50  per  cent,  alcohol  may  be 
used  sparingly  to  aid  in  removing  this.  Too  free  a  use  of 
alcohol  excoriates  the  delicate  skin.  Cleanse  the  clitoris 
carefully.  Follow  the  washing  with  a  free  application  of 
1:1000  aqueous  sublimate  solution  to  the  external  parts  and 
for  a  short  distance  inside  the  vtilvar  lips  and  to  the  clitoris. 
Do  not  introduce  disinfectants  into  the  healthy  vagina  nor 
deeply  into  the  vulva  as  it  will  cause  severe  straining  during 
and  subsequent  to  the  operation  and  by  injuring  the  vulvo- 
vaginal  mucosa  favor  subsequent  infection  of  the  vaginal 
wound.  Wash  away  the  sublimate  solution  with  a  tepid  .6 
per  cent,  soda  bicarbonate  solution,  and  fill  the  vulvo-vaginal 


102         VAGINAL  OVARIOTOMY  IN  THE  MARE. 

canal  with  the  same.  After  thorough  disinfection  of  the 
hands  and  arms  remove  the  disinfectants  by  washing  in 
sterile  soda  solution,  which  at  the  same  time  renders  the 
hand  unctuous  and  readily  introduced  through  the  vulva. 
Armed  with  the  guarded  sterilized  scalpel,  Fig.  10,  intro- 
duce the  right  hand  into  the  vagina  promptly  and  when  it  is 
well  "ballooned"  unsheath  the  knife  and  placing  it  just 
above'the  os  uteri  at  I,  Plate  XV,  parallel  to  the  long  axis 
of  the  uterus  and  a  few  mm.  to  the  right  or  left  of  the  median 
line,  in  order  to  avoid  a  loose  fold  of  mucous  membrane  gen- 
erally existing  directly  on  the  median  line,  the  blade  being 
held  vertical,  that  is  the  cutting  surface  parallel  to  the  longi- 
tudinal muscular  fibers  of  the  vagina,  and  guarding  the  pos- 
sible extent  of  its  introduction  with  the  thumb  and  fingers, 
push  it  directly  forward  in  a  straight  line  with  a  quick  thrust 
through  vaginal  mucosa,  the  muscular  walls  and  the  peri- 
toneum, until  the  disappearance  of  resistance  indicates  that 
the  peritoneum  has  been  penetrated.  This  is  the  most  criti- 
cal step  in  the  operation. 

If  the  hand  is  introduced  immediately  after  the  injection 
of  the  sterile  saline  solution  the  vagina  will  generally  be 
found  "  ballooned  "  or  will  quickly  become  inflated  under 
movements  of  the  hand.  If  the  solution  is  thrown  out  the 
vagina  may  collapse  and  closely  invest  the  hand,  in  which 
case  more  soda  solution  should  be  injected  when  it  will  again 
dilate.  If  the  hand  is  introduced  without  the  knife,  with- 
drawn and  then  introduced  with  the  knife  it  will  be  frequently 
found  that  the  vagina  has  collapsed  and  needs  a  second  fill- 
ing with  the  fluid.  Patience  until  dilation  is  accomplished 
and  promptness  to  act  when  attained  are  prime  requisites 
to  success.  The  knife  should  be  pushed  through  the  vagina 
quickly  making  a  clean  wound  the  width  of  the  knife  blade, 
when  the  latter  is  to  be  withdrawn  and  laid  aside.  It  should 
be  remembered  that  in  this  "  ballooned  "  state,  the  anterior 
wall  of  the  vagina  is  but  2  or  3  mm.  thick  and  easily  pene- 
trated. Introduce  the  hand  again,  push  one  finger  into 


VAGINAL  OVARIOTOMY  IN  THE  MARE.         103 

incision,  then  a  second  and  third  finger,  and  eventually 
holding  all  the  fingers  in  the  form  of  a  cone  push  the  entire 
hand  into  the  peritoneal  cavity.  Immediately  below  the  in- 
cision and  continuous  with  the  tissues  involved  in  the  wound 
lies  the  uterus  with  a  transverse  diameter  of  4  to  6  cm. 
With  the  palm  of  the  hand  downwards,  trace  the  uterus, 
U,  Plate  XV,  forward  a  distance  of  15  to  1 8  cm.,  where  it 
ends  abruptly  in  two  cornua  of  about  the  same  size  as  the 
uterus,  which  are  given  off  horizontally  at  almost  right 
angles.  Trace  these  to  the  right  and  left  for  a  distance  of 
14  or  15  cm.,  where  they  end  obtusely,  and  3  or  4  cm.  be- 
yond this  in  a  direct  line,  resting  upon  the  anterior  border 
of  the  broad  ligament  is  the  dense  oval  ovary  varying  in  size 
from  2.5  to  7  cm.  in  diameter.  Withdrawing  the  hand, 
carry  the  ecraseur  enclosed  within  it  through  the  vaginal 
wound  to  the  region  of  the  ovary,  release  the  ecraseur  and 
retrace  the  parts  if  necessary,  and  locating  the  ovary  drop 
the  chain  over  it  from  above  and  either  grasp  it  with  the 
fingers  through  the  chain  from  above  and  draw  it  into  the 
loop  or  passing  one  or  two  fingers  around  beneath  the  ovary 
push  it  up  through  the  loop  to  be  grasped  by  the  thumb  and 
index  finger  above.  The  chain  loop  should  be  of  barely 
sufficient  size  to  admit  of  the  easy  passage  of  the  ovary. 
Holding  the  ovary  with  one  hand  tighten  the  chain  quickly 
with  the  other,  examine  to  make  sure  that  a  loop  of  intes- 
tine is  not  caught,  draw  the  ovary  well  through  and  get  a 
large  portion  of  the  oviduct,  and  cut  off  promptly,  holding 
to  the  ovary  until  carried  out  through  the  vulva.  Remove 
the  other  ovary  in  the  same  way.  Generally  it  is  most  con- 
venient to  remove  the  left  ovary  with  right  hand  and  vice- 
versa,  but  both  may  be  removed  with  either  hand.  Wash 
away  any  blood  from  external  parts,  apply  sublimate  solu- 
tion freely  to  the  vulva,  perineum  and  tail.  Keep  the  pa- 
tient quiet  for  five  or  six  days,  and  feed  lightly  on  a  laxative 
diet. 


104         VAGINAL  OVARIOTOMY  IN  THE  MARE. 

DANGERS. 

Wounding  of  the  rectum  is  scarcely  possible  if  care  is 
taken  not  to  attempt  the  incision  until  the  vagina  is  well 
"  ballooned,"  and  then  making  the  stab  wound  directly  for- 
ward. If  made  upwards  when  the  organ  is  so  erected  the 
accident  is  highly  probable,  and  with  the  undilated  vagina 
where  it  is  necessary  to  cut  upwards  the  danger  is  ever  pres- 
ent. Its  prevention  demands  that  the  operator  await  the 
complete  "ballooning"  and  then  make  his  incision  as 
directed.  If  the  wound  in  the  rectum  passes  through  the 
pelvic  connective  tissue  behind  the  peritoneum  it  is  of  little 
consequence,  but  the  operation  should  be  abandoned  ;  if 
the  bowel  is  opened  into  the  peritoneal  cavity  the  accident 
is  fatal. 

"Wounding  of  the  iliac  arteries,  which  produces  prompt 
death  from  hemorrhage,  results  from  the  incision  being  made 
upwards  instead  of  forwards  either  when  the  vagina  is  "  bal- 
looned" or  collapsed.  It  is  most  likely  to  occur  with  timid 
operators  who  become  nervous,  especially  when  the  vagina 
does  not  "balloon"  promptly  or  the  mare  is  not  well 
secured.  The  accident  is  wholly  unnecessary  if  the  opera- 
tor will  await  the  "ballooning"  and  favor  it  if  need  be  by 
repeated  injections  of  tepid  soda  solution.  When  it  has  oc- 
curred it  is  generally  beyond  remedy. 

Wounding  of  the  uterus  may  occur  when  the  incision 
is  directed  downward  and  may  greatly  embarrass  the  opera- 
tor and  confuse  him  by  passing  the  hand  through  the  incis- 
ion into  the  uterine  cavity.  It  is  to  be  avoided  by  carefully 
directing  the  incision  straight  forwards  ;  when  the  accident 
occurs  it  is  of  little  consequence  beyond  the  embarrassment 
and  may  be  overcome  by  again  dilating  the  vagina  with 
fresh  injections  of  the  soda  solution  and  making  a  new  incis- 
ion, or  if  preferred  the  first  incision  may  be  corrected  by 
placing  an  index  finger  against  the  peritoneum  at  the  upper 
part  of  the  wound,  and  with  a  sudden  and  vigorous  thrust 


VAGINAL  OVARIOTOMY  IN  THE  MARE.         105 

break  through  the  peritoneum  into  the  cavity.  Great  care 
must  be  exercised  to  make  the  thrust  quickly  and  vigorously 
or  the  peritoneum  will  separate  from  the  adjoining  tissues 
and  a  large  cavity  be  formed  between  the  peritoneal  and 
muscular  walls  of  the  vagina  with  a  large  area  of  yielding 
membrane  which  it  is  difficult  to  penetrate.  It  is  not  very 
safe  in  such  cases  to  attempt  continuing  the  incomplete  in- 
cision with  the  scalpel,  as  it  is  very  yielding  and  pushes 
against  neighboring  organs  before  it  is  penetrated  and  affords 
no  signal  to  the  hand  by  cessation  of  resistance  when  it  has 
passed  through. 

Incomplete  penetration  of  the  vaginal  wall  is  liable  to 
occur  if  the  scalpel  is  dull  or  the  vagina  incompletely  "  bal- 
looned "  and  flaccid,  or  if  the  operator  is  unduly  timid.  It 
is  best  prevented  by  avoiding  the  cause  as  related,  and  once 
it  has  occurred  it  is  generally  best  to  again  "  balloon  "  the 
organ  and  make  a  new  incision  either  to  the  right  or  left  of 
the  first.  It  may  be  overcome  also  by  thrusting  the  index 
finger  through  the  peritoneum  as  described  in  the  preceding 
paragraph. 

The  mistaking  of  a  ball  of  feces  for  the  ovary  has  oc- 
curred to  inexperienced  operators  and  the  fatal  error  of  re- 
moving the  portion  of  the  rectum  surrounding  the  fecal  pellet 
committed.  The  blunder  is  uncalled  for  ;  the  fecal  ball  is 
movable  in  the  bowel,  the  intestine  is  far  more  massive  than 
the  broad  ligament,  and  the  ovary  is  to  be  definitely  identi- 
fied by  its  being  lodged  in  the  broad  ligament  just  beyond 
the  end  of  the  oviduct,  which  is  continuous  with  the  uterus 
and  coruna.  If,  therefore,  one  traces  the  uterus  forward  to 
the  coruna,  thence  along  these  to  the  oviducts,  and  thence 
along  the  border  of  the  broad  ligament  to  the  ovary,  as  above 
directed,  the  error  will  not  occur. 

The  incision  may  readily  be  made  too  low  and  pass 
beneath  the  broad  ligament.  It  is  to  be  avoided  by  being 
careful  to  keep  close  to  the  median  line  and  above  the  os  uteri. 


io6         VAGINAL  OVARIOTOMY  IN  THE  MARE. 

If  it  occurs  the  operation  may  be  completed  from  beneath 
without  very  great  difficulty  only  that  the  ovary  now  lies 
above  the  hand  and  must  be  drawn  down  from  on  top  the 
broad  ligament  in  order  to  fix  the  ecraseur  upon  it. 

Infection  constitutes  always  the  most  serious  danger  and 
is  to  be  avoided  by  proper  securing  of  the  animal,  by  the 
avoidance  of  irritant  antiseptics  in  the  vagina,  by  rigid  anti- 
sepsis at  every  stage,  and  by  carrying  out  the  mechanical 
parts  of  the  operation  deliberately,  vigorously  and  neatly. 
If  infection  should  occur  it  will  generally  take  the  form  of 
pelvic  cellulitis  with  abscesses  and  rectal  stricture.  Enemas 
of  a  normal  salt  or  soda  solution  affords  the  surest  relief  of 
the  stricture  and  impaction  in  front  of  it.  The  abscesses 
must  be  watched  and  opened  early  into  the  vagina  or  rec- 
tum, and  the  case  treated  internally  and  locally  according  to 
general  surgical  principles. 


VAGINAL  OVARIOTOMY  IN  THE  COW,  107 


27.     VAGINAL  OVARIOTOMY  IN  THE  COW. 

Objects.  Increasing  the  fat  or  milk-producing  qualities 
and  the  cure  of  nymphomania. 

Instruments.  Colin's  scalpel,  vaginal  dilator,  Miles' 
spaying  shears. 

Technic.  Confine  the  cow  in  the  standing  position  in 
the  stocks,  securing  the  head  firmly  and  passing  two  boards 
beneath  the  abdomen  and  sternum  to  prevent  lying  down, 
and  a  rope  over  the  middle  of  the  back  to  prevent  arching 
of  the  spinal  column  and  straining. 

Wash  and  disinfect  the  tail  and  the  perinaeum  and  flush  out 
the  vagina  with  a  .5  per  cent,  solution  of  carbolic  acid  or 
lysol  at  a  temperature  of  about  100°  F.  Insert  the  vaginal 
dilator  with  one  hand  and  push  the  prolongation  at  the  an- 
terior end  into  the  os  uteri.  With  the  other  hand  elevate 
the  handle  of  the  dilator  and  depress  and  push  forward  the 
uterus,  thus  rendering  the  roof  of  the  vagina  tense  and  push- 
ing it  downward  away  from  the  rectum.  Carry  the  scalpel 
into  the  vagina  with  the  right  hand  and  resting  it  in  the 
oval  of  the  dilator  make  an  incision  through  the  roof  of  the 
vagina,  beginning  at  a  point  8  to  10  cm.  posterior  to  the 
os  uteri  and  extending  backward  on  the  median  line  for  a 
distance  of  2  or  3  cm.  Be  careful  to  make  the  incision  en- 
tirely through  the  mucosa,  muscle  and  peritoneum  at  the 
first  cut,  since  any  failure  to  complete  the  incision  tends  to 
cause  the  peritoneum  to  separate  from  the  muscular  coat 
and  form  a  pocket  between  them,  while  the  peritoneum  be- 
ing very  elastic  renders  it  difficult  to  complete  the  incision. 
Introduce  two  fingers  through  the  incision,  and  reaching 
over  the  side  of  the  vagina  to  the  right  or  the  left,  the  right 
or  left  ovary  respectively  is  recognized  lying  immediately 
against  the  vagina  somewhat  below  it,  just  at  the  anterior 
border  of  the  pubis,  in  a  mass  consisting  of  the  cord-like 
Fallopian  tube  and  the  fimbrise  of  its  pavilion.  The  ovary 


108  VAGINAL  OVARIOTOMY  IN  THE  COW. 

may  be  distinguished  as  a  firm  oval  mass  2  to  40111.  in  length 
and  i  to  2  cm.  in  its  lesser  diameter  attached  to  the  broad 
ligament.  If  not  promptly  recognized  by  the  sense  of  touch, 
trace  the  vagina  and  uterus  with  the  fingers  forwards  from 
the  vaginal  incision  to  the  cornua  and  follow  them  as  they 
bend  upward  and  then  backward  to  the  Fallopian  tubes,  and 
trace  each  of  them  until  the  ovary  is  reached,  where  it  is  at- 
tached to  the  broad  ligament,  just  beyond  the  fimbriated  end. 
Grasp  the  ovary  between  the  index  and  middle  fingers  and 
draw  it  through  the  incision  into  the  vagina.  Introduce  the 
scissors  with  the  other  hand,  and  when  the  ovary  is  reached 
open  them  barely  sufficient  to  admit  the  broad  ligament 
between  the  blades  and  cut  away  the  ovary  along  with  a 
considerable  amount  of  the  broad  ligament.  It  is  essential 
that  plenty  of  the  broad  ligament  and  Fallopian  tube  be 
removed  with  the  ovary  in  order  to  insure  the  entire  removal 
of  the  latter,  because  the  accidental  leaving  of  the  smallest 
particle  of  ovarian  tissue  will  cause  a  development  of  these 
into  abnormally  large  Graafian  follicles,  and  will  tend  to  in- 
crease rather  than  decrease  nymphomania.  Should  the  ani- 
mal be  pregnant  the  ovary  on  the  gravid  side  is  dragged 
downward  and  forward  out  of  reach  of  the  operator's  fingers, 
and  if  it  is  desired  to  complete  the  operation  it  may  be  neces- 
sary to  enlarge  the  vaginal  wound  and  introduce  the  entire 
hand,  when  the  ovary  can  be  reached  and  removed.  No 
after  care  is  generally  necessary. 

The  Dangers  are  similar  to  those  of  the  mare.  The  iliacs 
may  be  wounded  in  the  same  manner  as  in  the  mare  and  is 
preventable  by  being  careful  to  push  the  vaginal  roof  wel 
downwards  away  from  the  rectum  and  pelvic  roof. 

A  new  danger  appears  in  the  presence  of  the  rumen,  the 
supero-posterior  portion  of  which  projects  into  the  pelvic 
cavity  when  filled  with  food  and  if  the  cut  is  directed  for- 
wards a  stab  wound  readily  penetrates  its  walls  with  fatal  re- 
sults. Make  the  cut  upwards  and  backwards. 


OVARIOTOMY  IN  THE  COW.  109 


28.     OVARIOTOMY  IN  THE  COW  BY  THE  FLANK. 

Instruments.  Clipping  shears,  convex  scalpel,  spaying 
shears,  heavy  needle  and  thread. 

Uses.  Same  as  the  preceding,  applicable  to  heifers  or  to 
cows  when  the  vulva  is  too  small  to  admit  the  operator's 
hand  or  in  case  of  diseased  vagina  or  uterus. 

The  animal  may  be  secured  as  in  the  preceding  or  con- 
fined in  lateral  recumbency  with  the  hind  legs  extended 
backward  and  the  anterior  limbs  forward.  To  accomplish 
this  loop  a  rope  about  the  two  fore  feet,  another  about  the 
two  hind  feet,  and  drawing  upon  these,  cast  the  animal  and 
secure  it  in  recumbency  with  the  legs  extended  and  body 
stretched  by  fastening  the  ropes  to  two  strong  posts  about 
8  to  10  m.  apart.  The  operation  may  be  performed  in  either 
flank. 

Clip  the  hair  from  the  upper  part  of  the  flank,  disinfect 
an  area  15  to  25  cm.  square  and  make  an  incision  about  12 
cm.  long  beginning  at  a  point  equi-distant  from  the  anterior 
tuberosity  of  the  ilium,  the  ends  of  the  transverse  processes 
of  the  lumbar  vertebrae  and  the  last  rib  and  extend  it  down- 
ward perpendicularly  severing  the  skin  and  subcutaneous 
muscle.  Divide  the  external  oblique  muscle  in  the  direction 
of  its  fibres  by  means  of  the  scalpel  handle  or  the  fingers 
and  repeat  the  process  upon  the  internal  oblique  muscle  after 
which  puncture  the  peritoneum  either  with  the  scalpel  or  by 
means  of  a  sudden  thrust  with  the  index  finger.  Force  one 
hand  through  the  opening  into  the  peritoneal  cavity  and 
search  for  the  ovaries  at  the  same  point  and  by  the  same 
method  as  in  the  preceding  operation,  that  is,  locate  the 
uterus  within  the  pelvic  cavity,  between  the  rectum  and 
bladder  and  trace  the  former  and  thence  the  cornu,  oviduct 
and  broad  ligament  to  the  ovary.  The  uppermost  ovary 
can  be  drawn  out  through  the  wound  and  cut  off  with  the 
scissors  ;  the  lower  one  must  be  held  with  one  hand  and  the 


no  OVA  RIO  TOM  Y  IN  THE  BITCH. 

scissors  introduced  closed  along  the  arm  and  when  the  ovary 
is  reached,  opened  barely  sufficient  to  pass  over  the  broad 
ligament  and  clip  it  off.  The  beginner  must  always  remem- 
ber that  the  positive  means  for  identifying  the  ovaries  is  by 
tracing  the  uterus  from  the  vagina  along  its  cornua  to  the 
Fallopian  tube  and  thence  to  the  ovary  in  the  broad  liga- 
ment. Cleanse  the  wound  and  close  the  skin  incision  with 
continuous  sutures. 


29.     OVARIOTOMY  IN  THE  BITCH  BY  THE  FLANK. 
PLATE  XVI. 

Instruments.     Spaying  knife,  suture  material. 

Technic.  Confine  the  animal  in  lateral  recumbency, 
preferably  upon  the  right  side  for  a  right  handed  operator, 
the  head  somewhat  depressed,  the  limbs  extended  and  the 
body  well  stretched.  Clip,  shave  and  disinfect  a  sufficient 
area  in  the  exposed  flank  at  a  point  just  anterior  to  and  be-\ 
neath  the  external  angle  of  the  ilium.  With  one  hand  grasp 
the  skin  fold  of  the  flank  and  render  the  skin  of  the  region 
tense,  while  with  the  other  holding  the  spaying  knife  like  a 
pen  make  at  first  a  drawing  ii.cision  from  below  upwrard  about 
2  to  3  cm.  long,  ending  above  at  a  point  slightly  below  the 
external  angle  of  the  ilium,  the  incision  extending  through 
the  skin  and  subcutaneous  tissues  ;  without  removing  the 
knife  from  the  wound  elevate  the  handle  and  with  a  quick 
thrust  make  a  stab  wound  extending  through  the  external 
and  internal  oblique  muscles  and  peritoneum  at  a  single  cut. 
The  operator  can  determine  when  the  peritoneal  cavity  has 
been  entered  by  the  disappearance  of  resistance.  Introduce 
an  index  finger  into  the  peritoneal  cavity,  and  as  soon  as 
this  has  been  entered  follow  directly  along  the  peritoneum 
upward  and  backward  toward  the  angle  of  the  ilium  where 
the  uterine  cornua  lie  covered  over  by  the  broad  ligament. 
The  internal  generative  organs  of  the  bitch  are  unique  among 


OVARIOTOMY  IN  THE  BITCH.  1 1 1 

our  domesticated  animals.  The  uterus,  U,  Plate  XVI,  is 
very  small  and  physiologically  unimportant,  the  cornua, 
RUC  and  LUC,  are  ample  in  size  and  constitute  physiolog- 
ically the  uterus,  the  Fallopian  tube  between  LUC  and  O 
is  ver}'  short  and  surgically  could  almost  be  said  not  to  ex- 
ist, the  ovary  OO  is  very  small,  smooth  and  completely  hid- 
den in  the  pavilion  which  here  constitutes  a  sac  having  a 
very  small  longitudinal  opening  of  2  to  5  mm.  The  most 
remarkable  feature  of  the  apparatus  from  a  surgical  stand- 
point is  the  great  development  of  the  broad  ligament  which 
is  broader  than  the  distance  from  the  lumbar  region  to  the 
abdominal  floor,  while  the  uterus  and  uterine  cornua  are 
stretched  between  the  vagina,  V,  and  the  ovary,  O,  so  that 
they  are  suspended  in  the  sub-lumbar  region  with  the  double 
fold  of  the  broad  ligament  hanging  down  like  a  curtain  be- 
tween the  parietal  peritoneum  and  the  uterus  and  cornua  on 
either  side.  The  broad  ligament  of  the  bitch  is  consequently 
suspended  at  one  point  from  the  sub-lumbar  region,  at  the 
other  from  the  uterus,  so  that  instead  of  the  uterus  being  sus- 
pended by  the  ligament  the  relation  is  reversed  and  the  liga- 
ment is  suspended  from  the  uterus,  or  rather  uterine  cornua. 
In  Plate  XVI  the  right  broad  ligament  BL'  is  laid  out  upon 
the  side  exposing  the  right  uterine  coriiu  RUC,  while  on 
the  left  side  the  ligament  is  divided  at  about  its  center  and 
the  posterior  portion  BL'  is  laid  out  on  the  flank,  while  the 
anterior  BL  is  left  in  its  normal  position  concealing  a  por- 
tion of  the  corn u  LUC.  Unlike  our  other  domesticated  ani- 
mals, the  broad  ligament  is  heavily  loaded  with  fat  which 
gives  it  an  appearance  very  similar  to  the  omentnm,  but  the 
net-work  is  far  less  conspicuous  or  wanting.  The  omentum 
also  extends  back  into  this  region  so  that  the  two  are  in  con- 
tact. The  ovary  being  indistinct  and  hidden  is  difficult  to 
identify  directly,  and  the  cornua  being  covered  over  by  the 
duplicature  of  the  broad  ligament  is  not  readily  reached,  so 
that  the  finger  generally  comes  in  contact  first  with  the  broad 
ligament  of  the  uppermost  cornu  hanging  loose  in  the  peri- 


Pl,ATE  XVI. 

OVARIOTOMY  IN  THE  BITCH. 

Abdomen  of  a  non  pregnant  bitch  lying  on 
the  back  with  the  abdominal  floor  removed  and 
the  omen  turn  pushed  away.  TT,  the  two  pos- 
terior teats  ;  B,  bladder  ;  V,  vagina  ;  U,  uterus  : 
LUC,  LUC,  left  uterine  "ciornua  with  a  portion 
of  its  broad  ligament,  BL,  lying  across  it ;  RUC, 
right  uterine  cornua  with  its  broad  ligament, 
BL7,  turned  outwards  exposing  the  full  length 
of  the  cornua.  On  the  left  side  the  ligament  is 
divided  so  that  the  anterior  half  rests  in  its  nor- 
mal position  while  the  posterior  half,  BLX,  is 
turned  back  ;  OO,  ovaries  ;  R,  rectum  ;  K,  left 
kidney  ;  AA,  a  line  indicating  the  level  of  the 
external  tuberosities  of  the  ilia. 


O  VARIO  TOM  Y  IN  THE  BITCH.  1 1 5 

toneal  cavity  ;  engage  this  between  the  end  of  the  finger  and 
the  abdominal  wall  and  draw  it  out  through  the  wound, 
grasp  it  and  continue  drawing  upon  the  folds  of  the  liga- 
ment, especially  upon  the  median  or  undermost  portion  until 
the  naked  cornu  appears  through  the  opening,  seize  it  and 
draw  out  the  anterior  portion  until  the  ovary  follows,  then 
grasp  the  ovary  firmly  with  the  thumb  and  index  finger  of 
one  hand  and  the  ovarian  ligament  with  the  same  members 
of  the  other  hand  and  tear  the  ligament  through  between 
them  by  linear  tension.  Extend  the  tear  through  the 
broad  ligament  as  high  toward  its  lumbar  attachment  as 
is  convenient  and  backward  to  the  neighborhood  of  the  uter- 
ine bifurcation.  Draw  upon  the  exposed  cornu  until  the  bi- 
furcation appears,  when  the  other  cornu  is  to  be  grasped  and 
drawn  out  through  the  opening.  In  young  puppies  the 
securing  of  the  second  cornua  is  very  difficult  and  requires 
great  care  to  prevent  its  rupture.  The  object  may  be  facili- 
tated by  pressing  the  upper  flank  of  the  bitch  downward, 
thereby  greatly  diminishing  the  transverse  diameter  of  the 
abdomen. 

The  succeeding  operation,  30,  avoids  this  difficulty  in  a 
large  measure.  Should  the  distal  cornu  be  ruptured  and 
with  its  ovary  drop  away  from  the  operator,  it  becomes  nec- 
essary to  turn  the  animal  over  and  make  a  second  incision 
on  the  opposite  side,  somewhat  further  forward.  When  the 
second  cornua  has  been  secured  draw  it  out  as  far  as  practica- 
ble and  holding  it  tense  insert  an  index  finger  along  it  until 
the  ovary  is  reached,  which  is  recognized  by  its  slightly 
greater  size  and  density  succeeding  the  brief  neck  represent- 
ing the  Fallopian  tube  between  the  end  of  the  cornu  and 
ovary  which  are  slightly  larger,  while  beyond  it,  can  be  felt, 
the  ovarian  ligament.  Engage  the  ligament  between  the  end 
of  the  index  finger  and  the  abdominal  wall,  and  with  a  firm 
and  vigorous  movement,  using  the  finger  end  and  nail  as  a 
curette,  rupture  the  ovarian  ligament  by  drawing  the  finger 
toward  the  incision,  and  with  the  aid  of  tension  upon  the 


n6  OVARIOTOMY  IN  THE  BITCH. 

cornu  draw  the  ovary  out  through  the  abdominal  incision 
and  divide  the  broad  ligament  as  in  case  of  the  other  cornu. 
Remove  the  cormia  with  the  attached  ovaries  by  rupturing 
them  transversely  near  the  bifurcation  by  means  of  linear 
tension. 

If  the  bitch  be  pregnant  and  especially  if  far  advanced  the 
uterine  coronna  will  lie  upon  the  abdominal  floor,  much  en- 
larged and  very  much  more  flaccid  than  the  nongravid  uterus 
and  feeling  very  much  like  intestines.  The  change  in  the 
position  of  the  uterus  has  caused  the  unfolding  of  the  dupli- 
cature  of  the  broad  ligament  so  that  it  no  longer  covers  the 
cornu.  In  such  cases  the  operation  is  performed  in  the  same 
way  except  that  rupturing  the  blood  vessels  by  linear  ten- 
sion does  not  insure  against  hemorrhage  and  it  is  necessary 
to  ligate  the  ovarian  and  uterine  arteries  with  catgut  or  silk. 
In  cases  of  pregnancy  the  entire  cornna  should  be  drawn 
out  and  a  strong  ligature  plactd  around  the  uterus  or  vagina  ; 
and  the  ovaries,  uterine  cornua  and  their  contents  be  re- 
moved en  masse.  Release  the  upper  posterior  limb  and  close 
the  cutaneous  wound  by  a  continuous  suture. 

Dangers.      Rupture  of  the  uterine  cornu  alluded  to  above. 

The  ureter  may  be  mistaken  for  the  cornu  but  is  smaller, 
is  closely  attached  to  the  abdominal  walls,  and  does  not 
have  the  broad  ligament  with  its  large  deposit  of  fat.  The 
kidney  is  far  larger  than  the  ovary,  more  exposed,  and 
located  more  anteriorly. 

The  iliac  arteries  are  at  times  caught  and  ruptured  by  the 
finger  but  the  blunder  is  uncalled  for  except  through  nervous- 
ness of  the  operator. 

Unauthentic  instances  of  puncturing  the  bladder  in  mak- 
ing the  incision  have  been  reported  and  may  be  possible. 
If  the  bitch  has  been  led  out  and  caused  to  urinate  prior  to 
operating,  the  accident  is  made  practically  impossible. 


O  VA  RIO  TOM  Y  IN  THE  BI TCH.  1 1 7 

30.     OVARIOTOMY  IN  THE  BITCH  BY  THE  LINEA  ALBA. 
PLATE  XVI. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Confine  in  the  dorsal  position  with  the  head 
sharply  declined.  Shave  and  disinfect  an  area  on  the  median 
line  about  6  cm.  square  extending  forward  from  the  pubic 
brim.  Make  an  incision  on  the  median  line  about  4  cm. 
long  beginning  just  in  front  of  the  pubic  brim  and  extending 
forward  cutting  entirely  through  the  skin,  the  linea  alba  and 
peritoneum  at  a  single  stroke.  Insert  an  index  finger  and 
identify  the  uterus  or  broad  ligament  by  its  location  and 
form.  The  finger  usually  comes  in  contact  first  with  the 
urinary  bladder  which  may  more  or  less  obstruct  the  pas- 
sage to  the  uterus  according  to  its  degree  of  distension. 
When  empty  as  shown  at  B,  it  offers  practically  no  obstruc- 
tion. When  very  much  distended  it  may  be  evacuated  by 
gentle  pressure  with  the  fingers.  The  operator  should  be 
careful  not  to  draw  the  bladder  out  through  the  incision  as 
its  replacement  may  prove  difficult  and  its  puncture  with  the 
hypodermic  needle  or  an  enlargement  of  the  incision  may  be 
necessary  in  order  to  bring  about  its  return.  Push  the 
bladder  aside  if  necessary  and  just  above  it  and  below  the 
rectum  the  uterus  should  be  readily  distinguished  and  either 
it  or  the  broad  ligament  caught  by  the  finger  and  brought 
out  through  the  incision  after  which  the  operation  proceeds 
in  the  same  manner  as  by  the  flank  method.  It  has  a  dis- 
tinct advantage  over  the  flank  method  in  that  in  puppies 
there  is  not  so  much  difficulty  in  bringing  out  the  ovaries, 
nor  the  danger  of  the  rupture  of  the  cornua  and  the  ovary 
dropping  back.  By  the  use  of  retractors  in  the  abdominal 
incision  the  operator  is  enabled  to  >ee  the  uterus  in  position 
and  grasp  it  by  means  of  forceps,  obviating  the  necessity  of 
introducing  the  finger  into  the  peritoneal  cavity.  The  sut- 
ures must  extend  entirely  through  the  abdominal  wall  and 
be  carefully  placed  in  order  to  prevent  hernia.  Interrupted 
sutures  are  preferable.  If  the  operation  has  been  properly 


Ii8  OVARIOTOMY  IN  THE  CAT. 

performed  no  bandage  is  necessary  and  the  patient  will  not 
disturb  the  sutures.  If  asepsis  has  not  been  strictly  fol- 
lowed infection  may  occur  and  the  consequent  irritation 
cause  the  patient  to  tear  the  sutures  out,  which  may  lead  to 
protrusion  of  the  intestines  or  other  abdominal  viscera.  If 
the  sutures  do  not  include  the  deeper  layers  of  the  abdominal 
wall  hernia  is  liable  to  occur  and  require  a  second  operation. 


31.     OVARIOTOMY  IN  THE  CAT. 

Instruments.     Same  as  for  the  bitch. 

Technic.  The  cat  may  be  spayed  by  either  the  flank 
method  or  through  the  linea  alba.  The  point  of  incision  in 
either  case  is  the  same  as  in  the  bitch  but  owing  to  the 
smaller  size  of  the  animal  it  is  necessary  to  make  the  wound 
quite  small.  The  abundance  of  hair  or  fur  in  the  region 
renders  it  essential  that  an  ample  area  be  shaved  and  the 
surrounding  hair  be  saturated  with  a  disinfectant  and  care- 
fully brushed  away  from  the  operative  area.  The  cat  being 
more  subject  to  infection  than  the  bitch  the  aseptic  precau- 
tions must  be  of  the  strictest  possible  character.  The  opera- 
tive area  must  be  thoroughly  disinfected  and  cleansed  and 
equal  care  must  be  taken  not  to  introduce  irritant  disinfect- 
ants into  the  wound.  A  great  danger  also  exists  in  the  ten- 
dency of  the  abdominal  muscle  layers  to  readily  become 
separated  by  pressure  from  the  finger  and  form  a  pocket  in 
which  wound  discharges  accumulate  and  constitute  a  danger- 
ous seat  for  infection.  Great  care  must  therefore  be  taken  to 
make  a  clean  incision  directly  into  the  peritoneal  cavity  and 
to  avoid  separating  the  peritoneum  from  the  muscles  or  the 
muscular  layers  from  each  other.  The  uterus  and  ovaries 
of  the  cat  are  naked  and  far  more  easily  distinguished  than 
in  the  bitch,  there  being  no  extra  deposit  of  fat  in  the  broad 
ligament.  The  sutures  are  to  be  applied  to  the  wound  in 
the  same  manner  as  in  the  bitch. 


TENOTOMY  OF  THE  FLEXOR  FED  IS  TENDONS.     119 

IV.     OPERATIONS  ON  THE  EXTREMITIES. 

32.     TENOTOMY  OF  THE  FLEXOR  PEDIS  TENDONS. 
PI.ATE  XVII. 

Objects.  The  relief  of  contraction  of  the  flexor  tendons 
of  the  foot. 

Instruments.  Razor,  scissors,  sharp  tenotome,  bandage 
material. 

Technic.  Tenotomy  is  generally  performed  on  the  deep, 
or  flexor  pedis  tendon,  seldom  on  the  superficial,  or  flexor 
of  the  os  coronae  of  the  foot. 

Confine  upon  the  operating  table  with  the  affected 
member  undermost  and  the  foot  fully  extended.  In  default 
of  a  table  confine  in  lateral  recumbency  and  apply  an  exten- 
sion splint  to  the  foot  as  shown  in  Plate  XVII. 

On  the  median  side  at  the  middle  of  the  metacarpus  the 
skin  is  shaved  and  disinfected  over  the  tendon  of  the  flexor 
pedis  muscle.  The  location  named  lies  between  the  lower 
extremity  of  the  great  carpal  sheath  above  and  the  superior 
extremity  of  the  tendonous  sheath  of  the  fetlock  below,  so 
that  neither  of  these  is  wounded  during  the  operation,  but 
the  tendon  is  severed  at  a  point  where  it  is  invested  by  loose 
-connective  tissue  which  retains  the  divided  ends  in  their 
normal  line  of  direction,  somewhat  fixed,  and  favors  their 
ultimate  reunion. 

Grasp  the  metacarpus  in  this  area  from  above  and  behind 
in  such  a  manner  that  the  thumb  rests  upon  the  median  or 
upper  surface  of  the  metacarpus,  and  the  index  and  second 
fingers  on  the  lateral  or  under  side  of  the  flexor  pedis  tendon. 
While  the  left  thumb  pushes  the  skin  toward  the  metacarpal 
Done,  that  is,  forward,  a  sharp  pointed  tenotome  held  per- 
pendicularly in  the  right  hand  is  introduced  with  the  cutting 
•edge  toward  the  hoof  through  the  skin,  subcutem  and  anti- 


o 

c    x 


fc  5 

w       *3 

{"•        *, 


S       5    -- 

W  .41 

PH  =7] 


5     O 
O      ^ 


^    o 

OJC    'w 


PERONEAL   TENOTOMY.  12 1 

brachial  fascia  down  to  the  flexor  pedis  tendon.  Immedi- 
ately on  the  anterior  border  of  the  tendon  insert  thetenotome 
so  far  that  the  point  of  it  can  be  felt  on  the  lateral  or  outer 
side  through  the  skin  with  the  left  hand.  The  cutting  edge 
of  the  knife  is  then  turned  against  the  tendon  of  the  flexor 
pedis,  that  is,  it  is  directed  backward,  the  foot  is  extended 
by  an  assistant  with  the  aid  of  a  rope  bound  around  the 
pastern  and  looped  over  the  hoof,  and  the  extensor  pedis 
tendon  is  cut  through  under  light  pressure,  by  the  operator 
pressing  downward  on  the  handle  of  the  knife,  using  the 
metacarpus  or  suspensory  ligament  as  a  fulcrum  upon  which 
the  back  of  the  tenotome  rests  as  a  lever.  A  loud  crackling 
as  well  as  the  disappearance  of  resistance  by  extension  shows 
that  the  tendon  is  severed.  By  keeping  as  close  to  the  an- 
terior border  of  the  tendon  as  possible  we  can  avoid  injury 
to  the  common  digital  artery,  the  internal  cutaneous  vein, 
and  the  internal  and  external  interosseous  veins  which  run 
between  the  flexor  pedis  and  the  suspensory  ligament. 

After  the  removal  of  the  knife  and  after  seeing  that  there 
is  a  wide  space  between  the  ends  of  the  tendon,  the  foot  is 
unbound  from  the  splint  and  a  bandage  applied  to  the  meta- 
carpus, which  rests  upon  the  fetlock  joint  and  remains  in 
position  for  eight  days.  Healing  of  the  cutaneous  wound 
by  primary  union.- 


33.  PERONEAL  TENOTOMY. 
PLATE  XVIII. 

Object.     The  relief  of  Stringhalt. 

Instruments.     Razor,  scissors,  sharp  tenotome. 

Technic.  On  the  lateral  side  of  the  metatarsus  a  triangle, 
d,  opening  toward  the  tarsus  is  formed  by  the  tendons  of  the 
extensor  pedis  longus  muscle,  /,  and  the  lateral  extensor  of 
the  foot,  <?,  which  unite  on  the  anterior  surface  of  the  middle 
of  the  metatarsus.  The  synovial  sheath  of  the  extensor 


PI.ATE  XVIII. 

PERONEAI,  TENOTOMY  FOR  STRINGHAI/T. 

Right  hind  foot  seen  from  the  external  side. 
The  skin  covering  the  lateral  extensor  of  the 
foot  is  laid  back  in  the  form  of  a  flap,  the  crural 
fascia  divided,  e,  Peroneal  tendon  ;  f,  crural 
fascia  ;  /,  tendon  of  the  anterior  extensor  pedis 
muscle  ;  d,  the  triangle  formed  by  /  and  e. 


7 


CUNEAN  TENOTOMY.  125 

pedis  longus  muscle  extends  interiorly  to  near  the  point  of 
juncture  of  the  two  tendons  ;  the  sheath  of  the  lateral  ex- 
tensor ends  below  3  to  4  cm.  above  the  point  of  union.  In 
the  middle  of  this  space  without  a  sheath,  which  is  3  to  4 
cm.  long,  and  below  the  annular  ligament  of  the  hock  the 
operation  is  carried  out.  After  the  skin  has  been  shaved 
and  disinfected,  confine  in  the  stocks  or  operate  upon  the 
standing  horse,  with  the  aid  of  local  anaesthesia,  a  twitch 
being  applied  to  the  nose  and  the  opposite  hind  foot  held  up 
with  the  side-line.  The  tendon  of  the  lateral  extensor  is 
easily  felt  under  the  skin  as  a  hard  cord  about  .7  to  i 
cm.  in  diameter.  Stretch  the  skin  and  with  the  back  of 
the  hand  toward  the  hock  grasp  the  tendon  with  the  thumb 
and  index  finger  of  one  hand,  insert  the  tenotome  with  the 
cutting  edge  toward  the  foot  perpendicularly  upon  the  tendon 
through  the  skin,  subcutem  and  aponeurosis  derived  from  the 
crural  fascia  ;  push  it  from  before  backward  under  the  tendon, 
turn  the  cutting  edge  against  it,  and  with  the  hock  extended 
sever  the  tendon  as  well  as  the  fascia  through  to  the  skin. 
In  accomplishing  the  section  of  the  tendon  the  knife  is  to  be 
used  as  a  lever  of  the  first  class  with  the  anterior  border  of  the 
metatarsus  acting  as  a  fulcrum.  If  the  tendon  has  been 
completely  severed  its  retracted  ends  may  be  felt  under  the 
skin  i  to  2  cm.  above  and  below  the  wound.  After  the  op- 
eration an  antiseptic  bandage  is  applied,  resting  upon  the 
fetlock.  The  bandage  should  remain  eight  days  and  the 
cutaneous  wound  heal  bv  first  intention. 


34.    CUNEAN  TENOTOMY. 
PI.ATE  XIX. 

Objects.  The  relief  of  spavin  lameness  and  as  an  adjunct 
to  peroneal  .tenotomy  for  stringhalt. 

Instruments.     Razor,  scissors,  straight  scalpel. 

Technic.  Most  horses  can  be  operated  on  standing,  with 
the  aid  of  cocaine,  otherwise  cast,  or  secure  on  the  operating 


PIRATE  XIX. 

CUNEAN  TENOTOMY. 

For  the  relief  of  spavin  lameness,  and  as  an 
adjunct  to  peroneal  tenotomy  in  stiinghalt. 
CT,  cunean  tendon.  The  dotted  line  crosses  the 
ergot. 


-CT 


NEUROTOMY.  129 

table,  on  the  affected  side  and  extend  the  tarsus.  Shave  and 
disinfect  an  area  5  to  6  cm.  square  on  the  inferior  median 
surface  of  the  hock  over  the  course  of  the  cunean  tendon  of 
the  chief  flexor  of  the  metatarsus,  as  indicated  in  Plate  XIX. 
Locate  the  tendon,  CT,  by  palpation  as  it  passes  obliquely 
downward  and  backward  and  make  a  transverse  incision 
about  i  cm.  below  the  inferior  border  of  the  tendon  at  a 
point  midway  between  the  anterior  and  posterior  borders  of 
the  hock,  or  slightly  anterior  thereto,  the  width  of  the  scal- 
pel blade.  Push  the  tenotome  flatwise  between  the  skin  and 
tendon,  as  shown  in  the  plate,  force  it  upwards  to  the  superior 
border  of  the  tendon,  then  turn  the  cutting'  edge  toward  it 
and  elevating  the  handle,  using  the  superior  border  of  the 
wound  as  a  fulcrum,  cut  the  tendon  through  from  without 
inwards.  By  firm  pressure  upon  the  tenotome  in  the  latter 
method  periosteotomy  is  simultaneously  accomplished.  The 
completion  of  the  operation  is  evidenced  by  the  separation 
of  the  cut  ends  of  the  tendon  leaving  a  well-marked  de- 
pression at  the  point  of  operation.  Disinfect  the  wound, 
apply  an  antiseptic  bandage  resting  upon  the  fetlock  and 
allow  to  remain  undisturbed  for  six  days.  Healing  by 
primary  union. 

NEUROTOMY. 

General  Remarks.  Neurotomy  is  performed  for  a  vari- 
ety of  objects,  such  as  the  relief  of  pain  in  a  sensitive  nerve 
itself,  as  in  trifacial  neurotomy,  u,  p.  48,  the  relief  of 
pain  or  lameness  in  a  par:  supplied  by  a  sensory  nerve,  or 
the  inhibition  of  motor  power,  as  in  the  "  cribbing"  opera- 
tion. 

The  following  neurotomies  are  designed  to  relieve  pain 
and  the  consequent  lameness  dependent  upon  a  pathologic 
condition  of  some  part  or  tissue  on  the  distal  side  of  the 
point  of  operation  and  to  which  the  divided  sensory  nerve  is 
destined. 
9 


1 30  NE  URO  TOM  Y. 

Netirotomy  of  a  sensory  nerve  is  always  a  painful  opera- 
tion, and  its  performance  without  anaesthesia  is  unjustifiable 
from  a  humane  standpoint,  and  cannot  be  so  well  done  either 
from  the  view  of  mechanical  correctness  or  the  carrying  out 
of  antiseptic  standards.  Some  neurotomies  can  be  well  per- 
formed on  the  standing  animal  if  it  is  quiet  and  the  operator 
is  experienced,  the  parts  being  rendered  insensitive  by 
means  of  cocaine  or  other  local  anaesthetics  ;  in  the  greater 
neurotomies  general  anaesthesia  is  called  for,  whether  viewed 
from  the  humane  or  operative  standpoint. 

The  confinement  of  animals  for  neurotomy  on  the  sensor)7 
nerves  of  the  extremities  for  the  relief  of  lameness  is  always 
to  be  viewed  as  a  critical  procedure  for  the  reason  that  the 
operation  is  generally  made  because  of  the  local  manifesta- 
tion of  a  more  or  less  general  disease  which  is  accompanied 
by  fragility  of  the  skeleton,  and  as  a  result  most  casting  acci- 
dents occur  in  cases  of  confining  for  neurotomy  or  firing  in 
cases  of  lameness  belonging  to  the  great  group  of  dry 
arthritis  or  spavin  family.  Casting  must,  therefore,  be  done 
with  the  greatest  possible  care,  a  id  the  operating  table  is  to 
be  constantly  and  greatly  preferred. 

Neurotomy  is  properly  a  last  resort  in  lameness  and  should 
not  otherwise  be  performed.  It  has  two  great  and  ever 
present  dangers.  If  the  part  deprived  of  sensation  is  too 
badly  diseased  to  bear  the  weight  and  resist  the  insult  result- 
ant upon  the  part  being  called  to  do  its  normal  or  even  an 
extra  amount  of  work,  it  must  ultimately  give  way,  the 
bones  become  fractured,  the  tendons  separate  from  the  bone, 
the  intra-ungular  tissues  lose  their  integrity  and  the  hoofs 
become  detached  (exungulation)  or  other  degenerative 
changes  take  place  as  a  result  of  causing  a  part  to  do  a  work 
for  which  its  condition  unfits  it. 

The  second  great  danger  occurs  from  wounds  or  other 
traumatisms  to  the  tissues  distal  to  the  operation  when  the 
unnerved  parts  are  not  rested  as  they  would  be  in  natural 


NEUROrOMY.  131 

conditions  when  injured  and  as  a  result  reparative  changes 
are  prevented  and  supplanted  by  retrograde  processes  with 
ultimate  death  of  the  part  and  of  the  animal. 

Nerves  are  generally  accompanied  by  satellite  arteries  and 
veins  which  are  always  liable  to  be  wounded  during  the 
operation  and  are  more  embarassing  because  of  the  hemor- 
rhage clouding  the  operation  field  and  inviting  error  than 
dangerous  because  of  the  loss  of  the  blood  itself.  It  is  essen- 
tial to  a  good  operation  that  the  hemorrhage  be  kept  under 
control  throughout  so  that  each  tissue  will  stand  out  in  good 
relief  and  the  nerve  reveal  its  identity  in  addition  to  its  loca- 
tion, size  and  relations,  by  its  intensely  white,  nacrous, 
striated  character,  The  test  of  compressing  the  nerve  in 
order  to  identify  it  by  the  resultant  pain  is  unsurgical  and 
unnecessarily  cruel. 

Sepsis  holds  an  important  place  in  considering  the  dangers 
of  neurotomy  because  the  infection  of  a  sensitive  nerve 
causes  very  great  pain  and  if  considerable  tends  to  cause  a 
false  neuroma  or  fibroma  in  the  connective  tissue  of  the 
nerve  trunk,  calling  for  a  second  operation  in  order  to  re- 
move the  tumor,  and  resultant  lameness. 

Neurotomies  should  consequently  be  performed  only  in 
properly  selected  cases,  the  smallest  possible  trunk  that  will 
sufficiently  relieve  the  pain  should  be  selected  for  the  opera- 
tion, it  should  be  performed  with  due  regard  for  suffering 
and  for  asepsis,  should  be  performed  quickly  and  neatly, the 
incisions  being  free,  laying  the  nerve  trunk  bare  without 
tearing  up  the  tissues  and  clouding  them  and  at  every  point 
aim  at  celerity,  accuracy  and  neatness. 


I32  DIGITAL  NEUROTOMY. 

35      DIGITAL  NEUROTOMY. 
PLATE  XX 

Objects.  The  relief  of  navictilar  lameness  in  cases  where 
plantar  neurotomy  is  not  deemed  necessary  or  advisable. 

Instruments.  Razor,  scissors,  scalpel,  probe  pointed 
bistoury,  tenacula,  aneurism  needles,  bandages. 

Technic.  Digital  neurotomy  may  generally  be  perform- 
ed on  the  standing  animal,  the  operative  area  having  first 
been  anaesthetized  by  means  of  cocaine  or  otherwise,  a 
twitch  applied  to  the  upper  lip  and  the  affected  foot  held  up 
by  the  assistant.  If  necessary  because  of  restlessness  of  the 
animal  or  inexperience  of  the  operator,  confine  on  the  oper- 
ating table  or  cast  the  animal  and  apply  the  extension  splint 
to  the  foot  to  be  operated  on  as  shown  in  Plate  XVII,  except 
that  the  lower  binding  cords  rest  on  the  metacarpus  instead 
of  the  pastern.  Extending  downwards  from  the  fetlock 
joint  toward  the  coronet,  between  the  posterior  border  of 
the  phalanges  and  deep  flexor  tendon  there  is  a  slight  furrow, 
at  the  posterior  part  of  which,  close  to  the  external  margin 
of  the  tendon,  lies  the  median  or  principal  digital  nerve  ac- 
companied in  front  by  the  digital  artery,  A,  anterior  to 
which  lies  the  digital  vein,  V.  Immediately  behind  the 
nerve  and  generally  lying  a  trifle  deeper,  is  quite  commonly 
found  a  second  venous  trunk  of  considerable  size.  Near  the 
middle  of  the  first  phalanx  the  nerve  is  crossed  externally 
in  an  oblique  direction  from  above  to  below  and  from  behind 
to  before  by  a  white  ligarnentous  band,  L,  slightly  broader 
than  the  nerve  extending  from  the  base  of  the  ergot  of  the 
fetlock  to  the  retrossal  process  of  the  pedal  bone.  This  must 
not  be  mistaken  for  the  nerve,  N,  and  need  not  be  if  it  is  re- 
membered that  the  latter  is  accompanied  on  the  same  plane 
and  in  a  like  direction  by  the  satellite  artery,  A,  and  vein,  V, 
enclosed  with  it  in  a  fibrous  sheath.  At  the  uppermost  part 


DIGITAL  NEUROTOMY.  133 

of  the  first  phalanx  the  nerve  lies  in  front  of  this  ligament, 
a  short  distance  inferiorly  it  passes  beneath  it,  while  from 
the  middle  of  the  pastern  downwards  the  nerve  lies  behind 
the  ligament. 

The  operation  is  practicable  at  any  point  over  the  line  of 
the  nerve  from  the  top  to  the  bottom  of  the  shaved  area  in 
Plate  XX  or  from  the  superior  end  of  the  first  phalanx  down 
to  a  level  with  the  superior  border  of  the  lateral  cartilage, 
but  perhaps  preferably  at  about  the  middle  of  the  pastern. 
At  the  desired  point  and  over  the  groove  between  the  flexor 
pedis  tendon  and  the  phalanges  shave  and  disinfect  an  area 
4  to  5  cm.  square.  In  the  center  of  this  area  at  the  anterior 
border  of  the  flexor  tendon,  with  the  scalpel  held  perpen- 
dicular to  the  skin,  make  an  incision  from  above  downwards 
a  distance  of  from  2  to  3  cm.  cutting  cleanly  through  the 
skin  and  subcutaneous  fascia  down  upon  the  nerve.  The 
incision  is  favored  by  tensing  the  skin  between  the  thumb 
and  index  finger  of  the  left  hand,  but  care  should  be  taken 
not  to  displace  it  backwards  or  forwards.  Dilate  the  wound 
by  pressure  with  the  thumb  and  index  finger  or  otherwise 
and  carefully  incise  longitudinally  the  fibrous  sheath  en- 
veloping the  nerve  and  artery.  Pass  an  aneurism  needle 
beneath  the  nerve,  and  follow  with  a  second  aneurism  needle 
immediately  beside  the  first.  Draw  the  two  apart,  one 
toward  the  toe,  the  other  toward  the  fetlock,  and  separate 
thereby  the  nerve  from  the  surrounding  tissues.  Remove 
one  aneurism  needle,  insert  a  probe  pointed  scalpel,  or  scis- 
sors beneath  the  nerve,  and  divide  it  at  the  upper  angle  of 
the  wound  and  excise  a  section  of  nerve  3  cm.  long.  Disin- 
fect and  bandage  with  or  without  suturing  the  wounds. 
Leave  the  bandage  in  place  6  to  8  days. 


PIRATE  XX. 
DIGITAL  NEUROTOMY. 

V,    digital  vein  ;  A,  digital  artery  ;  N,  digital 
nerve  ;  L,  ligament. 


PLANTAR  NEUROTOMY.  137 

36.     PLANTAR  NEUROTOMY. 
PLATE  XXI. 

Objects.  The  relief  of  navicnlar  lameness  or  other  pain- 
ful non-suppurating  diseases  of  any  parts  below  the  fetlock 
joint. 

Instruments.  Razor,  scissors,  convex  scalpel,  compres- 
sion artery  forceps,  tenacula,  aneurism  needles,  suture  ma- 
terial, elastic  ligature. 

Technic.  It  is  well  to  apply  a  bandage  saturated  with 
sublimate  or  creolin  solution  to -the  fetlock  joint  24  hrs. 
before  the  operation  in  order  to  secure  thorough  disinfection. 

Confine  the  animal  and  fix  the  limb  as  in  the  preceding 
operation.  After  the  removal  of  the  bandage,  shave  the  site 
of  operation  and  thoroughly  disinfect  the  region  of  the 
metacarpus  and  fetlock  with  soap,  brush,  and  sublimate  or 
creolin  solution  and  50%  alcohol.  Passing  the  fingers  from 
before  to  behind  with  light  pressure  over  the  region  of  the 
fetlock  joint,  there  is  felt  just  in  front  of  the  flexor  pedis 
tendon  a  channel-like  depression  extending  from  above  the 
fetlock  downward  over  it.  In  this  lies  the  threadlike  cord 
of  the  nerve,  n,  3  mm.  thick,  which  glides  forward  under- 
neath the  fingers  with  a  distinct  recoil.  The  site  of  opera- 
tion lies  immediately  above  the  fetlock  in  the  posterior  third 
of  the  metacarpus  or  one  may  operate  at  any  point  higher 
up  as  far  as  beyond  the  middle  of  the  metacarpus  or  meta- 
tarsus so  long  as  care  ia  taken  to  include  the  anastomosing 
branch  given  off  by  the  median  plantar  nerve  at  about  the 
middle  of  the  metacarpus  and  bending  obliquely  around 
behind  the  tendons  to  join  the  lateral  nerve  somewhat  lower 
down.  At  this  point  stretch  the  skin  between  the  thumb 
and  index  finger  of  one  hand  and  make  an  incision  3  to  5 
cm.  long,  the  lower  angle  of  which  is  just  above  the  fetlock 
joint,  cutting  directly  through  the  skin,  subcutem  and  con- 


PLATE  XXI. 
PLANTAR  NEUROTOMY. 

a,  lateral  digital  artery  ;  z>,  lateral  digital  vein  ; 
«,  common  lateral  digital  nerve ;  d,  anterior 
branch  ;  o,  posterior  branch  ;  s,  superficial  flexor 
tendon  ;  p,  perforans  tendon  ;  /,  suspensory 
ligament  of  fetlock  ;  ;«,  metacarpus. 


or  THE 
UNIVERSITY 


NEUROTOMY  OF  THE  MEDIAN  NERVE.          141 

nective  tissue  sheath  down  on  to  the  nerve,  laying  it  bare. 
The  borders  of  the  cutaneous  wound  are  held  apart  with 
tenacula  and  by  palpation  with  the  fingers  or  by  vision  it  is 
determined  if  the  nerve  lies  in  the  middle  of  the  wound.  If 
necessary  continue  the  dissection  with  the  scalpel  until  the 
nerve  is  clearly  revealed  ;  it  is  distinguished  by  its  faintly 
yellowish  color,  its  fine  longitudinal  striae  and  its  location 
behind  the  metacarpal  artery.  Immediately  above  the  fet- 
lock joint  the  median  metacarpal  or  metatarsal  nerve  divides 
into  an  anterior  smaller,  d,  and  posterior  larger,  o,  branch. 
This  division  should  be  laid  bare  in  order  that  the  operator 
may  not  erroneously  cut  one  branch  only.  Immediately 
above  this  point  of  division  the  aneurism  needle  is  passed 
under  the  nerve,  then  a  second  needle  is  inserted  beside  it 
and  the  two  pulled  apart  separating  the  nerve  from  the  ad- 
jacent tissues,  the  scissors  or  a  small  probe-pointed  bistoury 
is  passed  beneath  and  it  is  cut  through  quickly  at  the  superior 
angle  of  the  wound.  The  distal  end  of  the  nerve  is  then 
dissected  free  as  far  as  possible  downward  and  both  brandies 
excised  at  the  lower  angle  of  the  wound  so  that  a  section 
3  to  5  cm.  long  is  removed.  The  cutaneous  wound  is  united 
by  a  continuous  suture  and  a  temporary  bandage  applied. 
The  extension  splint,  if  it  has  been  used,  is  then  removed, 
the  foot  replaced  in  the  hobble  and  the  horse  turned  to  the 
other  side.  Neurotomy  of  the  opposite  metacarpal  nerve  is 
carried  out  in  the  same  way  after  which  a  sterile  bandage  is 
applied  and  allowed  to  remain  eight  days.  Healing  by 
primary  union. 


37.     NEUROTOMY  OF  THE  MEDIAN  NERVE. 
PI.ATE  XXII. 

Objects.  The  relief  of  lameness  due  to  disease  so  located 
in  the  anterior  limb  that  it  cannot  be  overcome  by  plantar 
neurotomy. 


142        NEUROTOMY  OF  THE  MEDIAN  NERVE. 

Instruments.  Razor,  scissors,  convex  scalpel,  artery 
and  compression  forceps,  tanacula,  aneurism  needles,  suture 
material. 

Technic.  The  operation  is  performed  on  the  median 
surface  of  the  anterior  limb  immediately  below  the  hurnero- 
radial  articulation  on  the  recumbent  horse  after  the  affected 
foot  has  been  fully  extended  on  the  operating  table  or  in  de- 
fault of  this  removed  from  the  hobbles  and  bound  upon  the 
extension  splint  as  shown  in  Plate  XVII.  Anaesthetize. 
The  foot  is  drawn  out  firmly  from  the  shoulder,  inclined 
somewhat  forward.  The  operator  places  himself  between 
the  neck  and  the  forearm  and,  after  the  median  region  of 
the  elbow  joint  has  been  washed  with  soap  and  water, 
searches  for  the  median  nerve  where  it  glides  over  the  pos- 
terior part  of  the  joint  to  disappear  behind  the  radius. 
Shave  the  skin  at  and  below  this  point,  disinfect  it  with 
soap,  sublimate  or  creolin  solution  and  50^  aclohol.  The 
nerve,  n,  lies  as  a  rule  somewhat  in  front  of  the  middle  of  the 
median  side  of  the  forearm  against  the  postero-internal 
margin  of  the  radius  and  can  be  felt,  about  5  to  6  mm.  in 
diameter,  lying  somewhat  deeply.  The  position  of  the  nerve 
varies  with  the  different  attitudes  of  the  forearm.  In  fat 
and  fleshy  horses  the  identification  of  the  nerve  is  more 
difficult.  It  may  be  felt  upon  the  standing  animal. 

With  the  nerve  lying  between  the  thumb  and  index  finger 
of  the  left  hand,  at  the  point  where  it  begins  to  disappear 
behind  the  radius  after  having  passed  over  the  humero-radial 
articulation  stretch  the  superposed  skin  and  immediately 
upon  and  parallel  to  it  make  an  incision  5  cm.  long,  first 
through  the  skin,  then  through  the  sterno-aponeuroticus 
muscle.  Any  hemorrhage  from  the  skin,  subcutis,  or  mus- 
cle, is  checked.  The  tenacula  are  inserted  cautiously  in  the 
lips  of  the  wound,  and  these  being  drawn  apart  the  white 
anti-brachial  fascia  is  brought  into  view  and  a  search  is 
made  with  the  index  finger  to  determine  the  exact  location 


NEUROTOMY  OF  THE  MEDIAN  NERVE.          143 

of  the  nerve,  and  the  fascia  is  divided  with  the  scalpel  and 
an  oval  piece  excised  with  the  scissors  immediately  over  it. 
If  much  fatty  tissue  is  found  between  the  layers  of  fascia  it 
may  be  dissected  away  carefully  with  the  scalpel  or  cut  away 
with  the  scissors.  There  now  comes  to  view  a  delicate  red- 
dish colored  fascia-like  membrane,  the  nerve  sheath,  behind 
which  a  blue  cord,  the  brachial  vein,  V,  is  visible,  the  latter 
being  intimately  connected  with  the  nerve  sheath.  The 
ve'n  lies  mostly  behind  and  beneath  the  nerve  and  may  pro- 
ject out  from  beneath  the  anterior  border  of  the  same.  The 
operator  needs  be  careful  not  to  prick  this  vein  with  the 
tenacula,  as  the  hemorrhage  therefrom  is  exceedingly  annoy- 
ing during  the  operation.  It  is  best  to  avoid  the  use  of 
tenacula  after  penetrating  the  fascia  and  retract  the  wound 
lips  cautiously  with  the  aneurism  needles  instead.  Still 
further  forward  and  deeper  may  be  felt  the  pulsating  brachial 
artery.  Incise  the  nerve  sheath  carefully  and  divide  it  upward 
and  downward  with  the  scalpel  or  scissors,  whereupon  the 
yellowish  and  distinctly  fibrous  nerve  comes  into  plain  view. 
Pass  an  aneurism  needle  beneath  the  nerve  then  pass  another 
alongside  the  first  and  drawing  the  two  apart  separate  the 
nerve  from  the  adjacent  tissues  throughout  the  length  of  the 
wound.  Be  careful  to  not  cut  the  nerve  too  high  and  errone- 
ously include  the  motor  nerve  of -the  flexor  of  the  metacarpus 
and  the  flexors  of  the  foot,  which  are  generally  given  off  pos- 
teriorly just  below  the  humero  radial  articulation.  Lift  the 
nerve  up  and  cut  it  through  at  the  superior  angle  of  the 
wound  by  a  sudden  clip  with  the  scissors  or  with  the  probe 
pointed  scalpel.  Lay  the  peripheral  end  of  the  nerve  bare 
to  the  lower  angle  of  the  wound,  and  excise  at  least  3  cm. 
of  it.  Tamponade  the  wound  with  dry  iodoform  gauze  and 
approximate  the  skin  with  a  continuous  suture.  The  tampon 
and  sutures  remain  from  i  to  2  days. 

Since  sensation   of  the   lower   part  of  the  limb  is  partly 
maintained  by  the  deep  branch  of  the  ulnar  nerve  which  at 


PI.ATE  XXII. 
MEDIAN  NEURECTOMY. 

Median  surface  of  the  right  humero-radial 
articulation,  a,  brachial  artery ;  n,  median 
nerve  ;  v,  brachial  vein  ;  /,  antibrachial  fascia  ; 
p,  sterno-aponeuroticus  muscle. 


10 


NEUROTOMY  OF  THE  ULNAR  NERVE.  147 

the  lower  part  of  the  carpus,  covered  by  the  tendon  of  the 
oblique  flexor  becomes  the  lateral  plantar  nerve,  nenrotomy 
of  the  median  nerve  does  not  completely  effect  the  desired 
end.  In  order  to  produce  complete  anaesthesia,  therefore, 
from  median,  it  is  necessary  at  the  same  time  to  perform 
ulnar  neurotomy. 


38.     NEUROTOMY  OF  THE  ULNAR  NERVE. 
PI.ATES  XXIII  AND  XXIV. 

Objects.  An  adjunct  operation  to  the  preceding  by 
which  the  enervation  of  the  carpus  and  foot  is  completed. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Above  and  behind  the  carpus  there  may  be 
felt  a  groove  between  the  external  and  middle  flexors  of  the 
carpus,  EF  and  OF,  Plate  XXIV.  At  this  point  10  cm. 
above  the  pisiform  bone  the  skin  is  shaved  and  disinfected 
and  an  incision  6  cm.  long  made  through  the  skin  and 
antibrachial  fascia.  This  incision  extends  just  outside  the 
median  line  of  the  posterior  surface  of  the  radius  in  such  a 
way  that  the  superior  angle  of  the  wound  is  about  I  cm. 
farther  outward  than  the  lower.  Beneath  the  fascia  between 
the  aforesaid  muscles  is  seen  the  ulnar  nerve,  Plate  XXIII, 
n,  Plate  XXIV,  NU,  on  the  median  or  inner  side  of  it 
the  collateral  ulnar  vein,  Plate  XXIII  v,  and  between  the 
two  and  somewhat  deeper  the  collateral  ulnar  artery,  a. 
The  nerve,  about  3  mm.  in  diameter  is  picked  up  with  the 
aneurism  needle,  severed  at  the  upper  and  lower  angles  of 
the  wound,  the  lips  of  the  wound  united  by  a  continuous 
suture  and  a  bandage  applied.  Healing  by  first  intention. 


PLATE  XXIII. 
NEUROTOMY. 


Right  forearm  seen  from  behind.  <?,  external 
flexor  of  the  carpus;/,  oblique  (middle)  flexor 
of  the  carpus  ;  a,  collateral  ulnar  artery  ;  d,  anti- 
brachial  fascia  ;  «,  ulnar  nerve. 


PI.ATE  XXIV. 


UI,NAR  NEUROTOMY. 

Cross  section  through  the  radius  of  the  limb 
about  10  cm.  above  the  pisiform  bone,  viewed 
from  below.  EF,  external  flexor  of  the  carpus  ; 
OF,  oblique  flexor  of  the  carpus  ;  NU,  ulnar 
nerve  ;  NM,  median  nerve.  Lying  on  its  median 
side  is  the  ulnar  artery,  the  satellite  vein  of 
which  is  not  shown. 


SCI  A  TIC  NEURO  TOMY.  1 53 

39.     SCIATIC  NEUROTOMY. 
PLATES  XXV  AND  XXVII. 

Objects.  The  destruction  of  sensation  in  the  tarsus  and 
parts  beyond  for  the  relief  of  otherwise  incurable  spavin 
lameness,  diseases  of  the  tendons,  etc. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Place  the  animal  on  the  operating  table  on  the 
diseased  side,  extend  the  affected  limb  and  draw  the  upper 
leg  forward  and  secure  it  out  of  the  way.  Produce  complete 
general  anaesthesia.  The  posterior  tibial  or  sciatic  nerve  n, 
Plate  XXV,  and  NS,  Plate  XXVII,  is  then  sought  by  grasp- 
ing the  leg  with  the  left  hand  from  behind  in  such  a  manner 
that  the  thumb  rests  above  and  the  fingertips  below  it. 
Reaching  forward  with  the  fingers  to  the  deep  flexor  of  the 
foot  grasp  the  leg  with  moderate  firmness  and  draw  the  hand 
slowly  backward.  Immediately  behind  the  perforans  muscle 
and  between  this  and  the  tendo- Achilles  the  nerve  nearly  i 
cm.  in  diameter  glides  away  forward  from  between  the 
fingers  with  a  distinct  recoil.  If  the  nerve  can  not  be  found 
in  this  manner  the  hock  should  be  strongly  extended,  by 
which  means  it  is  caused  to  recede  from  the  perforans  mus- 
cle, so  that  it  can  more  readily  be  felt  near  the  middle  of  the 
groove  extending  between  it  and  the  tendo-Achilles.  At 
this  point  the  skin  is  shaved,  disinfected  and  an  incision 
made  through  it  5  cm.  long,  parallel  to  the  tendo-Achilles. 
The  white  rigidly-stretched  crural  fascia  is  now  divided  in 
the  same  direction  after  which  it  should  be  determined  by 
palpation  that  the  nerve  lies  in  the  middle  of  the  wound. 
Excise  with  the  scissors  an  elliptic  or  oval  piece  of  the  fascia 
or  hold  apart  the  fascia  along  with  the  lips  of  the  cutaneous 
wound  by  means  of  the  tenacula.  In  poor  horses  the  con- 
tour of  the  nerve  covered  only  by  loose  connective  tissue 
stands  out  prominently,  in  fat  horses  it  is  surrounded 


PI,ATE  XXV. 
SCIATIC  NEUROTOMY. 

Right  hind  leg  viewed  from  the  median  side, 
y,  crural  fascia;  ?/,  sciatic  (tibial)  nerve;  v, 
plantar  vein. 


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PJ.ATE  XXVI. 
ANTERIOR  TIBIAI,  NEUROTOMY. 

EP,  extensor  pedis  muscle  ;  P,  peroneus  mus- 
cle ;  NP,  deep  branch  of  the  peroneal  or  anterior 
tibial  nerve  ;  FM,  flexor  metatarsi  muscle. 


1 1 


UNIVERSITY 

OF 


ANTERIOR  TIBIAL   NEUROTOMY,  16.3 

by  a  large  amount  of  adipose  tissue.  Cut  through  this  fat 
and  connective  tissue  and  the  tibial  nerve,  nt  Plate  XXV  and 
NS,  Plate  XXVII,  is  in  sight,  immediately  before  it  lies  the 
plantar  vein  and  on  the  lateral  side  is  situated  the  recurrent 
tibial  artery  SA,  Plate  XXVII.  The  cross  section  in  Plate 
XXVII  is  located  somewhat  below  the  point  for  operation 
and  the  vein  has  crossed  obliquely  over  the  nerve  so  that  it 
appears  behind  instead  of  in  front  of  it,  as  is  the  case  gen- 
erally at  the  point  where  the  operation  is  performed.  Sep- 
arate the  vessels  completely  from  the  nerve  with  the  handle 
of  the  scalpel,  pass  two  aneurism  needles  from  before  back- 
ward beneath  it  and  drawing  these  apart  separate  the  nerve 
trunk  from  the  adjacent  tissues  and  cut  it  off  at  the  upper 
and  lower  angles  of  the  wound  removing  a  section  at  least 
5  cm.  long.  Suture  the  cutaneous  wound  and  apply  a 
bandage  allowing  it  to  remain  eight  days.  Healing  by  first 
intention. 


40.      ANTERIOR  TIBIAL  NEUROTOMY. 

NEUROTOMY  OF  THE  DEEP  BRANCH  OF  THE  PERONEAL  NERVE. 
PLATES  XXVI  AND  XXVII. 

Object.  An  adjunct  operation  to  the  preceding  as  it  sup- 
plies sensation  to  the  tarsus  in  common  with  the  sciatic. 
The  two  constitute  what  is  known  as  Bossi's  double  neuro- 
tomy  for  spavin. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Confine  as  in  the  preceding  but  with  the 
affected  leg  uppermost.  Locate  the  furrow  dividing  the  ex- 
tensor pedis  longus  muscle,  EP,  Plates  XXVI  and  XXVII, 
and  the  peroneus  muscle,  P,  Plate  XXVI,  MP,  Plate  XXVII, 
and  shave  and  disinfect  the  skin  over  an  area  6  cm.  long  by 
3  cm.  wide  directly  over  this  depression  and  extending  up- 


1 64  ANTERIOR  TIBIAL   NEUROTOMY. 

ward  from  a  point  6  or  7  cm.  above  the  tibio-astragoloid 
articulation. 

At  a  point  8  to  10  cm.  above  the  flexure  of  the  hock  make 
an  incision  through  the  skin  and  subcutis  5  or  6  cm.  long 
over  the  line  of  division  between  the  two  extensors  of  the 
foot.  Superficially  the  operator  passes  near  by  the  muscttlo- 
cutaneous  division  of  the  anterior  tibial  nerve,  NMC,  Plate 
XXVII,  which  must  not  be  mistaken  for  the  deep  branch. 

The  peroneus  muscle,  MP,  Plate  XXVII,  and  P,  Plate 
XXVI,  is  separated  from  the  extensor  pedis  longus,  KP, 
Plates  XXVI  and  XXVII,  by  a  strong  aponenrotic  sheath 
continuous  with  the  tibial  aponeurosis.  Penetrate  the  latter 
anterior  to  the  aponeurotic  partition  directly  against  the  ex- 
tensor pedis,  EP.  and  passing  along  its  posterior  border  to  a 
depth  of  2  to  4  cm.,  there  appears  the  thin  margin  of  the 
flexor  metatarsi  magnus  KM,  Plates  XXVI  and  XXVII, 
which  lies  immediately  against  the  extensor  pedis  without  a 
visible  connective  tissue  partition  but  revealing  itself  by  a 
markedly  lighter  shade  of  color  and  its  ready  separation 
with  the  scalpel  from  the  extensor.  The  deep  branch  of  the 
peroneal  nerve,  NP,  Plates  XXVI  and  XXVII,  lies  loosely 
imbedded  on  the  anterior  side  of  the  margin  of  the  flexor 
metatarsus  facing  the  extensor  pedis,  at  times  visible  at  the 
margin,  at  others  placed  more  deeply  reaching  in  some  cases 
a  distance  from  the  margin  of  4  or  5  mm.  Within  this 
range  is  seen  the  slender  nerve  trunk  almost  devoid  of 
surrounding  connective  tissue  and  measuring  about  2  mm. 
in  diameter.  Pass  the  aneurism  needle  beneath  it  and  re- 
move a  piece  3  to  4  cm.  long.  Close  the  cutaneous  wound 
with  interrupted  sutures  and  dress  antiseptically  without  a 
bandage. 


RESECTION  OF  THE  LATERAL  CARTILAGE.    165 

41.    RESECTION  OF  THE  LATERAL  CARTILAGE. 
PI,ATE  XXVIII. 

Object.     The  cure  of  quittor  or  necrosis  of  the  cartilage. 

Instruments.  Elastic  ligature,  drawing  knife,  scissors, 
razor,  hoof  rasp,  hoof  plane,  craniotomy  or  other  heavy  for- 
ceps for  the  removal  of  the  horn,  artery  forceps,  elevator  or 
long  bone  chisel,  double-edged  sage  knife,  curette,  needle 
holder,  thread,  needles,  iodoform  ether,  iodoform  gauze, 
tampons,  absorbent  cotton,  bandages. 

Technic.  For  a  few  hours  before  the  operation  place 
the  affected  foot  in  a  bath  of  creolin  solution  after  having 
first  made  a  semicircular  groove  in  the  horn  of  the  lateral 
wall  and  quarter  down  to  the  horny  lamina,  as  shown  at  s 
in  Fig.  i,  Plate  XXVIII. 

The  operation  is  performed  upon  the  recumbent  anaes- 
thetized animal,  in  such  a  position  that  the  diseased  cartilage 
of  the  affected  foot  lies  upward.  The  operating  table  consti- 
tutes incomparably  the  best  means  of  confinement  in  every  re- 
spect. After  the  application  of  the  elastic  ligature  the  groove 
in  the  horn  is  deepened  with  the  drawing  knife 'down  to  the 
sensitive  laminae  without  injuring  them.  The  groove  must  be 
so  located  that  it  extends  beyond  the  anterior  and  posterior 
borders  of  the  lateral  cartilage,  remaining  a  few  cm.  distant 
from  the  bearing  surface  of  the  wall  and  approximately  per- 
pendicular to  the  surface  of  the  horn  wall  so  that  it  will  form 
a  secure  support  for  the  dressing  to  be  later  applied.  The 
hair  on  the  coronary  band  is  clipped  or  shaved  and  the  entire 
foot  up  to  the  fetlock  joint  thoroughly  cleansed  with  brush, 
soap,  creolin  or  sublimate  solution  and  50  per  cent,  alcohol. 
The  levator  or  long  bone  chisel  is  then  inserted  beneath  the 
lowest  part  of  the  semi-circular  piece  of  horn  which  has  been 
isolated,  the  horn  is  elevated  from  the  sensitive  structures 
somewhat,  grasped  with  the  heavy  forceps  and  carefully  loos- 
ened from  the  sensitive  laminae  by  drawing  upward  parallel 


1 66      RESECTION  OF  THE  LATERAL  CARTILAGE. 

to  the  laminae  and  then  backward  from  the  coronary  papillae 
and  keraphyllotis  tissue.  After  the  coronary  band  has  been 
smoothed  vvitli  the  scissors,  make  two  perpendicular  incis- 
ions through  the  skin  of  the  coronary  band  and  the  band 
itself,  one  behind  the  anterior  and  the  other  in  front  of  the 
posterior  border  of  the  groove  in  the  horn  and  connect  the 
two  by  means  of  a  semi-circular  incision  in  the  sensitive 
laminae.  This  U-shaped  incision  must  be  so  made  that  be- 
tween it  and  the  horny  wall  there  is  left  an  area  of  sensitive 
laminae  at  least  2  cm.  wide,  in  order  that  there  may  be  suffi- 
cient room  in  the  soft  tissues  for  the  application  of  the  su- 
tures, as  shown  in  Fig  2.  The  isolated  flap  is  now  dis- 
sected closely  against  the  os  pedis  and  its  ala  and  later  from 
the  lateral  surface  of  the  cartilage,  the  operator  first  lifting 
the  flap  with  forceps,  later  with  the  hand.  Above  the  carti- 
lage toward  the  fetlock  the  operator  must  keep  the  fingers 
of  one  hand  against  the  external  skin  in  order  to  avoid  cut- 
ting through  it  or  thinning  it  too  much  at  this  point.  The 
flap  is  held  turned  upwards  by  an  assistant  or  by  a  suture. 
As  a  rule  there  is  now  seen  a  prominent,  greenish  colored 
necrotic  piece  of  cartilage  surrounded  by  brownish  red 
masses  of  granulations.  By  means  of  an  incision  through 
the  cartilage  parallel  to  the  axis  of  the  foot,  divide  it  into 
anterior  and  posterior  halves  and  extirpate  the  latter  first, 
by  dissecting  it  out  on  the  inner  side  from  the  parachondrial 
tissue  with  the  double-edged  sage  knife.  The  point  of  the 
knife  must  be  constantly  directed  against  the  cartilage. 
Since  the  inner  surface  of  the  anterior  half  of  the  cartilage 
lies  immediately  against  the  capsular  ligament  of  thecorono- 
pedal  articulation  the  latter  should  be  sharply  extended  by 
which  means  the  capsular  ligament  is  drawn  away  from  the 
cartilage  during  its  extirpation.  The  anterior  half  of  the 
cartilage,  k,  is  then  removed  in  the  same  way,  except  with 
the  greatest  possible  care  to  avoid  puncturing  the  corono- 
pedal  articulation.  Remnants  of  cartilage  at  its  juncture 


PLATE 


FIG.  i. 
RESECTION  OF  THE  LATERAL  CARTILAGES  OF  THE  os  PEDIS. 

Horny  wall  removed,  sensitive  laminae  and  cutaneous  flap  held 
upwards.  Posterior  half  of  the  cartilage  excised.  _/,  sensitive  lam- 
inae ;  2V,  coronary  band  ;  £,  anterior  half  of  cartilage  ;  //,  cavity 
caused  by  the  removal  of  the  posterior  half  of  the  cartilage  ;  n,  necrotic 
cartilage  ;P,  parachondral  surface  of  the  skin  and  sensitive  laminae  ; 
s,  perpendicular,  crescent-shaped  incision  in  the  horny  wall  ;g,  fistula. 


XXVIII. 


FIG.  2. 
RESECTION  OF  THE  LATERAL  CARTILAGES  OF  THE  os  PEDIS. 

Completed  operation  showing  the  sutures  in  place    and  the  parts 
ready  for  the  application  of  dressings. 


RESECTION  OF  THE  LATERAL  CARTILAGE.       171 

with  the  retrossal  process  of  the  os  pedis,  and  granula- 
tions are  to  be  removed  with  the  curette.  Cut  away  with 
the  scissors  and  knife  any  remnants  of  cartilage  adher- 
ent to  the  flap,  p,  thin  if  necessary  the  entire  flap  and  excise 
the  fistulous  openings,  g.  After  thorough  disinfection  of  the 
entire  field  of  operation  return  the  flap  to  its  former  position 
and  retain  it  there  by  a  sufficient  number  of  interrupted 
sutures,  Fig.  2,  irrigate  the  wound  surface  with  iodoform 
ether  and  cover  the  parts  over  with  iodoform  gauze  and 
tampons  which  rest  firmly  upon  the  perpendicular  wall  of 
horn.  Finally  invest  the  hoof  and  pastern  up  to  the  fetlock 
joint  with  oakum  and  lay  a  heavy  tar  bandage  over  it,  the 
turns  of  which  must  completely  invest  it  at  every  point  and 
render  the  dressing  impermeable  to  moisture.  Remove  the 
elastic  ligature.  If  the  animal  is  free  from  fever,  feels  and 
eats  well,  the  bandage  is  left  in  position  from  12  to  14  days. 
Healing  by  first  intention. 


172    RESECTION  OF  THE  FLEXOR  FED  IS  TENDON. 

42.    RESECTION  OF  THE  FLEXOR  PEDIS  TENDON. 
FIG.  12. 

Object.  The  removal  of  necrotic  tissues  and  disinfection 
in  cases  of  infected  wounds,  chiefly  of  nail  pricks  of  the 
navicular  bursa. 

Instruments.  Elastic  ligature,  drawing  knife,  double- 
edged  sage  knife,  scissors,  tenaculum  forceps,  curette, 
scalpels,  tenaculse,  bandage  material. 

Technic.  Before  the  operation  thin  the  horn  of  the  sole, 
frog  and  bars  until  the  soft  parts  can  be  seen  through  them 
and  apply  an  antiseptic  bandage  saturated  in  creolin  solution 
for  24  hours  if  time  will  warrant.  Secure  the  patient  on  the 
operating  table  or  by  casting  in  lateral  recumbency  with  the 
affected  foot  extended.  Anaesthetize.  Cleanse  and  disinfect 
the  entire  foot  with  soap,  brush,  creolin  or  sublimate  solution 
and  50%  alcohol  and  apply  the  elastic  tourniquet  in  the 
metacarpal  or  metatarsal  region.  Make  a  transverse  incision 
through  the  base  of  the  frog  2  to  3  cm.  from  the  balls 
through  the  horny  and  sensitive  portions  and  the  fatty 
cushion  down  to  the  flexor  pedis  tendon.  Follow  this  by 
two  curved  incisions  extending  forward  and  inward  in  an 
oblique  direction  corresponding  to  the  semi-lunar  crest  of  the 
os  pedis,  the  line  of  incision  being  in  the  bars  about  ^  cm. 
outward  from  the  lateral  groove  of  the  frog  and  uniting  at 
its  apex.  This  triangular  piece  of  frog  which  has  been 
isolated  by  the  incision  is  now  grasped  with  the  tenaculuni 
and  dissected  away.  As  a  general  rule  the  operator  finds 
that  he  has  not  yet  reached  the  flexor  pedis  tendon  but  only 
the  fatty  cushion  which  covers  the  latter.  The  remnants 
of  the  fatty  frog  should  be  removed  with  the  double-edged 
sage  knife  or  scalpel  by  means  of  a  horizontal  incision,  and 
there  is  then  seen  the  greenish  or  yellowish  colored  necrotic 
flexor  pedis  tendon,  which  may  at  times  be  covered  with 


RESECTION  OF  THE  FLEXOR  FED  IS  TENDON.     173 

reddish  colored  granulations.  Should  the  operation  be  in- 
dicated on  account  of  a  suppurative  pododermatitis  the  bars 
on  the  affected  side  must  be  excised  along  with  the  other 
portions.  The  position  and  extent  of  the  navicular  bone 
can  be  determined  by  feeling  through  the  flexor  tendon.  A 
transverse  incision  is  then  made  over  the  middle  of  the 
navicular  bone  through  the  flexor  pedis  tendon  into  the 
navicular  bursa,  the  distal  end  of  the  tendon  grasped  with 


FIG.  12. 
RESECTION  OF  THE  FLEXOR  PEDIS  TENDON. 

Solar  surface  of  the  foot,  r,  Semilunar  crest  of  os  pedis  ; 
u,  os  pedis  ;  r,  navicular-pedal  ligament ;  s,  navicular  bone  ; 
b,  flexor  pedis  tendon  ;  e,  sensitive  laminae  of  the  bars  ;  st, 
fatty  frog  ;_/",  sensitive  frog  ;  /iy  horny  frog. 

the  tenaculum  forceps  and  lifted  up  from  the  navicular  bone 
with  the  aid  of  two  lateral  curved  incisions.  Between  the 
inferior  border  of  the  navicular  bone  and  the  semi-lunar  crest 
of  the  os  pedis  stretches  the  capsular  ligament  of  the  in- 
ferior articulation  between  these  two  bones  reinforced  by 
dense  fibrous  bands.  The  flexor  pedis  tendon  is  united  to 


174    AMPUTATION  OF  THE  CLA  WS  OF  RUMINANTS. 

this  by  a  few  bundles  of  fibres.  Dissect  the  tendon  carefully 
away  from  the  capsular  ligament,  avoiding  opening  the 
articulation,  and  beyond  from  the  semi-lunar  crest  of  the  os 
pedis.  If  necrotic  or  discolored  pieces  of  the  fatty  cushion 
or  the  tendon  still  remain,  remove  these  with  scissors,  scalpel 
or  curette.  With  the  latter,  currette  the  roughened  cartilage 
of  the  navicular  bone  and  remove  any  necrotic  portions- 
In  extensive  necrosis  of  the  suspensory  ligaments  of  the 
heel  and  of  the  ligaments  extending  from  the  fetlock 
joint  to  the  lateral  cartilages,  the  necrotic  portions  as  well 
as  the  neighboring  fatty  cushion  with  its  numerous  elastic 
fibres,  must  be  resected.  Disinfect  the  operation  wound, 
irrigate  with  iodoform  ether  and  tamponade  it  with  dry 
iodoform  gauze.  Over  this  apply  a  firm  pad  of  oakum, 
enclose  the  entire  hoof  up  to  the  fetlock  in  oakum  and 
apply  over  this  a  bandage.  Over  this  apply  a  tar  bandage 
and  remove  the  elastic  ligature.  In  the  absence  of  fever 
the  bandage  remains  in  position  for  eight  days. 


43.    AMPUTATION  OF  THE  CLAWS  OF  RUMINANTS. 
PIRATE  XXIX. 

Uses.  The  cure  of  "foul  in  the  foot"  or  panaritium 
when  complicated  with  suppurative  arthritis  or  osteitis. 

Instruments.  Half  round  rasp,  double-edged  sage  knife, 
scissors,  convex  scalpel,  nrtery  forceps,  drawing  knife, 
elastic  ligature. 

Technic.  Cast  the  animal  and  secure  the  foot  to  be 
operated  upon  in  an  extended  position,  apply  the  elastic 
ligature  after  disinfecting  the  claws  with  soap,  water,  brush 
and  creolin  solution,  rasp  away  the  horn  on  the  lateral  side 
of  the  diseased  claw,  especially  at  the  posterior  part  of  it, 
until  the  horny  wall  becomes  so  thin  that  it  can  readily  be 
pressed  in  with  the  fingers.  Anaesthetize.  The  corono- 


AMPUTATION  OF  THE  CLAWS  OF  RUMINANTS.     175 

pedal  articulation  can  be  felt,  about  3  cm.  below  the  coronary 
band,  by  grasping  the  claw  with  the  left  hand  in  such  a  man- 
ner that  the  thumb  rests  upon  the  thinly  rasped  horn  while 
with  the  other  hand  the  claw  is  moved  from  side  to  side. 
At  the  lowest  point  of  the  articulation  push  the  double- 
edged  sage  knife  into  the  joint,  the  concavity  of  the  knife 
being  directed  towrard  the  fetlock,  and  make  a  curved  incis- 
ion at  first  forward  and  upward  to  the  neighborhood  of  the 
coronary  band,  then  with  strong  flexion  of  the  foot  a  second 
curved  incision  backward  and  upward  which,  how7ever,  ex- 
tends only  to  the  navicular  bone.  By  this  incision  the  oper- 
ator divides  the  horn,  the  sensitive  lamina,  the  external 
corono-pedal  ligament  and  the  capsular  ligament  of  the 
corono-pedal  articulation.  Pass  the  knife  between  the  na- 
vicular and  pedal  bones  and  extend  the  incision  downwards 
perpendicular  to  the  solar  surface  through  it,  separating  the 
navicular  bone  from  the  os  pedis.  In  this  manner  the  na- 
vicular bone  is  preserved  as  well  as  the  ball  of  the  heel,  the 
latter  of  which  is  of  special  significance  in  healing.  The 
inner  wall  of  the  claw  with  the  powerfully  developed  corono- 
pedal  ligament  is  divided  from  before  backward.  After  the 
vessels  which  can  be  seen  are  ligated,  the  articular  surfaces 
of  the  navicular  and  coronary  bones  curetted  and  the  necrotic 
remnants  of  tendon  removed  an  antiseptic  bandage  is  applied 
and  a  tar  bandage  placed  over  it  for  protection.  The  band- 
age remains  for  12  or  14  days. 

If  the  structures  above  this  point  of  amputation  are 
irremediably  involved  the  digit  should  be  amputated  higher 
up,  at  the  articulation  of  the  first  and  second  phalanges  or 
through  the  first  phalanx.  In  these  higher  amputations  a 
flap  operation  is  generally  practicable. 


PIRATE  XXIX. 
AMPUTATION  OF  THE  CI<AWS  OF  RUMINANTS. 

FIG.  i.  d,  horny  wall,  rasped  thin  ;  g,  artic- 
ular condyle  of  2nd  phalanx  ;  a,  b,  c,  course  of 
incision. 

FIG.  2.  Median  claw  preserved.  Viewed 
from  the  solar  surface  outward.  «,  external 
corono-pedal  ligament ;  /,  internal  do  ;  k,  ten- 
don of  the  flexor  pedis  muscle  ;  g,  distal  artic- 
ular surface  of  the  2nd  digit  ;  g' ',  articular  sur- 
face of  3rd  digit  ;  g"  navicular  bone  ;  /,  lateral 
claw  ;  m,  median  claw  ;  b,  bulb  of  the  heel. 


FIG    i 


FIG.  2. 


12 


v  or  THE 


THE  BA  YER  SUTURE. 


179 


44.     THE  BAYER  SUTURE. 
FIG.  13  and  14. 

Uses.  The  closure  of  large  or  penetrant  wounds  with 
convenient  and  secure  means  for  applying  and  retaining 
antiseptic  dressings. 

Instruments.  Large  curved  suture  needle  armed  with 
strong  silk  thread,  about  20  cm.  long,  which  is  doubled  and 


FIG    13. 
RETENTION,  AND  CONTINUOUS  APPROXIMATION  SUTURES. 

dt  d' ',  df> ',  drainage  tubes  ;  ^,  retention  suture  (closed  end);  e' ',  open 
end  ;  d,  fixation  suture  for  the  drainage  tube  ;/~,  continuous  approxi- 
mation suture. 

passed  through  the  eye  in  such  a  manner  that  the  closed  end 
extends  considerably  beyond  the  cut  ends  ;  small  needles 
and  thread  ;  needle  forceps  ;  drainage  tubing  preferably  two 
very  large  and  one  small  with  lateral  openings  ;  thin  wooden 


i8o  THE  BAYER  SUTURE. 

splints  15  cm.  long,  2  to  4  cm.    wide,    with   rounded   ends; 
iodoform  gauze;  iodoform  ether  1:10. 

Technic.  After  the  skin  has  been  shaved  over  an  area 
having  a  radius  of  5  to  6  cm.  from  the  wound,  the  suture 
needle  is  inserted  2  to  3  cm.  from  the  lips  through  the  skin 
and  subjacent  tissues,  a  strong  drainage  tube,  d' ,  passed 


FIG.  14. 
SPLINT  BANDAGE. 

d,  df ,  d/f ,  drainage  tubes  ;  e,  retention  suture  (closed  end);  e' ',  do, 
open  end  ;/,  iodoform  gauze  ;  s,  splints. 

through  the  closed  end  of  the  suture  and  the  thread  drawn 
tight.  If  before  threading  the  needle  a  clove  hitch  is  made 
at  the  middle  of  the  thread,  or  if  threaded  as  above  directed 
and  the  thread  is  thrown  about  the  tube  in  a  double  noose, 
the  two  threads  will  be  kept  in  contact  as  they  leave  the  tube 
and  enter  the  soft  tissues  and  thus  prevent  to  some  degree, 
the  pressure  necrosis  otherwise  taking  place,  due  to  the  tense 


THE  BAYER  SUTURE.  181 

threads  of  the  suture  separating  from  each  other.  The 
needle  is  then  passed  through  the  opposite  lip  of  the  wound 
from  within  to  without  at  the  same  distance  from  the  lips, 
the  needle  removed,  the  free  ends  drawn  taut  and  a  single 
knot  tied  against  the  skin  to  prevent  the  separation  of  the 
two  threads  for  the  reasons  just  stated  above,  the  second 
large  drainage  tube,  d" ,  is  laid  between  the  open  ends  of 
the  double  silk  thread  and  these  are  tied  upon  it  with  a 
triple  knot,  after  they  have  been  drawn  sufficiently  tight 
that  the  approximated  wound  lips  form  a  crest.  If  the  lips 
of  the  wound  can  be  grasped  with  the  hand  and  held  to- 
gether in  such  a  manner  as  to  form  a  ridge  3  or  4  cm.  high, 
the  suture  needle  can  be  passed  through  both  simultaneously. 
The  first  suture  should  be  located  about  3  cm.  beneath  the 
upper  angle  of  the  wound,  the  other  retention  sutures  follow 
at  distances  of  about  5  cm.  from  each  other  and  applied  in 
the  same  way.  The  lips  of  the  wound  are  united  by  contin- 
uous approximation  sutures  like  an  overcasted  seam.  This 
suture  ends  at  least  2  cm.  above  the  lower  angle  of  the 
wound.  The  third  drainage  tube  is  introduced  into  the 
latter  and  fixed  by  a  special  suture.  The  entire  cutaneous 
surface  lying  between  the  drainage  tubes  is  covered  with 
iodoform  gauze,  and  between  each  two  retention  sutures 
there  is  laid  over  this  gauze  the  wooden  splints  previously 
cut  to  the  proper  size,  the  ends  of  which  are  shoved  under 
the  tubing.  The  upper-  and  lowermost  splints  should  be  se- 
cured to  the  drainage  tubing  by  means  of  sutures  passed 
through  them.  The  entire  bandage  is  finally  saturated  with 
iodoform  ether.  The  bandage  and  retention  sutures  remain 
eight  days,  the  approximation  sutures  fourteen. 


II.     EMBRYOTOMY  OPERATIONS. 

General  Considerations.  The  following  exercises  in 
embryotomy  operations  are  designed  to  give  to  the  student 
a  general  view  of  the  subject  by  a  simple  plan  as  carried 
out  through  the  aid  of  a  skeleton  provided  with  an  artificial 
uterus  into  which  are  placed  freshly  killed,  newly  born 
calves  in  such  a  position  as  may  be  desired  and  the  opera- 
tions carried  out  by  the  student  as  described.  At  the  same 
time  it  is  hoped  to  offer  through  these  descriptions  to  the 
veterinary  obstetrist  a  simple  and  effective  plan  for  perform- 
ing embryotomy  which  has  been  fully  tested  by  the  author 
in  an  extensive  obstetrical  practice.  In  describing  these 
operations  we  purposely  limit  the  instruments  to  be  used  to 
the  fewest  number  and  simplest  kinds,  yet  using  all  that  are 
essential  in  the  performance  of  any  of  the  following  obstet- 
rical operations.  We  designate  the  same  instruments  for 
each  operation.  They  are  :  a  hooked  ring  knife  ;  a  Colin' s 
scalpel  like  Fig.  n  ;  an  embryotomy  chisel  i  m.  in  length, 
the  handle  1.5  cm.  in  diameter  with  a  ring  end,  the  blade 
about  10  cm.  long  by  4  cm.  wide  and  2  to  3  mm.  thick,  the 
cutting  edge  concave  from  side  to  side  and  the  corners  dull 
and  rounded  ;  mallet ;  several  cotton  ropes  i  cm.  in  diame- 
ter with  a  small  spliced  loop  at  one  end. 


45.     CEPHALOTOMY. 

Object.  The  diminution  of  the  size  of  the  head  on  ac- 
count of  its  oversize  or  of  the  smallness  of  the  maternal 
pelvis,  so  that  it  will  pass  through  the  pelvic  canal. 

Technic.  In  these  cases  the  head  is  usually  engaged  in 
the  canal  sufficiently  tight  that  no  further  fixation  is  neces- 
sary. After  thoroughly  cleansing  and  disinfecting  the  parts 


1 84  CEPHALOTOMY. 

inject  a  copious  amount  of  tepid  lysol  solution  into  the  va- 
gina, then  carry  thr  chisel  carefully  guarded  by  one  hand  into 
the  passage  and  place  it  accurately  upon  that  part  of  the  head 
of  the  foetus  where  it  is  desired  to  begin  the  operation  ; 
generally  on  the  median  line  of  the  nose  with  the  blade  of 
the  chisel  standing  parallel  to  the  septum  nasi  of  the  fetus. 
Holding  the  blade  of  the  chisel  firmly  against  the  part  with 
one  hand  in  such  a  manner  as  to  effectively  guard  the  in- 
strument from  slipping  aside  and  wounding  the  maternal 
organs,  steady  and  direct  the  handle  with  the  other  hand 
and  have  an  assistant  drive  the  chisel  by  means  of  blows  of 
proper  vigor  with  the  mallet  into  the  bones  of  the  face  and 
head.  Do  not  drive  the  chisel  deeper  than  the  length  of 
the  blade  without  stopping  and  forcibly  revolving  the  chisel 
upon  its  long  axis  and  breaking  the  foetal  bones  apart. 
The  partially  detached  pieces  of  bone  may  be  torn  away 
with  the  fingers  or  in  case  the  skin  is  quite  adherent  to  them 
the  bone  may  be  held  with  the  fingers  of  one  hand,  the 
chisel  introduced  with  the  other  and  using  it  as  a  spatula 
separate  the  skin  from  the  bone.  Repeat  the  use  of  the 
chisel  as  often  as  may  be  necessary  in  order  to  bring  about 
the  required  diminution  of  the  head,  care  being  taken  at 
all  times  to  not  wound  the  maternal  parts  and  to  conserve  as 
far  as  practicable  the  skin  of  the  face  and  head  in  order  that 
it  may  protect  the  maternal  parts  from  the  jagged  bones 
during  the  passage  of  the  remains  of  the  head.  The  re- 
moval of  the  partially  detached  pieces  of  bone  may  in  many 
cases  be  greatly  facilitated  by  looping  one  of  the  cords  over 
them  and  having  an  assistant  apply  traction  sufficient  to  pull 
them  away,  the  operator  guarding  the  maternal  organs  by 
holding  the  piece  of  bone  during  its  detachment  and  extrac- 
tion, in  the  palm  of  his  hand. 


DECAPITATION.  185 


46.     DECAPITATION. 

Objects.  The  facilitation  of  repulsion  and  correction  of 
deviation  of  fetal  parts.  The  operation  is  generally  carried 
out  when  the  foetal  head  is  far  advanced  in  the  pelvic  canal 
or  has  passed  beyond  the  vulva. 

Technic.  Attach  a  cord  to  the  inferior  maxilla  or  around 
the  neck  of  the  foetus  and  have  one  or  more  assistants  draw 
the  head  out  as  far  as  possible.  Make  a  circular  incision 
through  the  skin  encircling  the  head  at  a  convenient  point 
and  separate  the  skin  backward  toward  the  occiput  "by  forc- 
ing the  hand  between  it  and  the  bones  or  by  using  the  chisel 
as  a  spatula  or  dissecting  it  away  with  the  Colin 's  scalpel, 
continuing  the  separation  over  the  occiput  to  the  atloid 
region.  Make  a  transverse  incision  below  across  the  trachea 
and  oesophagus  and  surrounding  muscles  and  above  through 
the  ligainentum  nuchae.  Grasp  the  head  firmly  with  both 
hands  and  twist  it  forcibly  on  its  long  axis  rupturing  the 
articular  ligaments  and  the  remaining  muscles  and  other  soft 
tissues,  detaching  the  head  at  the  occipito-atloid  articulation. 
The  removal  of  the  head  greatly  diminishes  the  bulk  of  the 
foetus  and  it  may  now  be  repelled,  or  deviated  parts  brought 
into  the  desired  position  or  other  operations  performed. 


47.     SUBCUTANEOUS  AMPUTATION  OF  ANTERIOR  LIMB. 

Objects.  Amputation  of  the  anterior  limbs  is  very 
frequently  called  for  in  obstetric  practice  especially  in 
the  mare,  chiefly  in  cases  of  transverse  presentation  with 
all  four  feet  presenting  where  it  may  be  impossible  to  safely 
correct  the  deviation,  in  cases  of  wry  neck  in  the  foal  in  the 
anterior  presentation,  dprso-sacral  position  when  it  is  impos- 
sible to  correct  the  deviation  of  the  head  or  in  any  case  in 
the  mare  or  cow  where  deviation  of  the  head  cannot 


1 86  SUBCUTANEOUS  AMPUTATION. 

be  corrected  or  is  not  so  readily  overcome  as  is  the   amputa- 
tion of  the  limb. 

Technic.  Our  larger  herbivorous  animals  being  devoid 
of  a  clavicle,  the  anterior  limb  is  attached  to  the  thorax  by 
means  of  the  skin  and  muscles  only  and  is  therefore  compar- 
atively easily  amputated.  Attach  a  cord  to  the  pastern  of  the 
limb,  the  shoulder  of  which  lies  most  exposed  or  is  most 
readily  reached  and  have  one  or  two  assistants  exert  traction 
on  it  and  draw  the  limb  out  as  far  as  possible  with  safety  to  the 
mother.  Insert  one  hand  armed  with  the  hooked  embry- 
otomy  knife  up  to  the  top  of  the  scapula  or  as  nearly  thereto 
as  can  be  reached,  the  knife  being  well  guarded  in  the  palm 
of  the  hand  which  rests  against  the  limb  of  the  foetus  ;  press 
the  knife  into  the  skin  and  subcutaneous  tissues  and  drawing 
the  hand  downward  slit  them  freely  and  deeply  from  the  top 
of  the  scapula  down  to  the  pastern.  Lay  aside  the  knife  and 
force  the  fingers  between  the  skin  and  subjacent  tissues  of 
the  limb  and  while  the  assistant  maintains  gentle  traction 
upon  the  limb  separate  the  skin  upward  by  forcing  the  hand 
or  the  ball  of  the  thumb  through  the  loose  connective  tissues 
until  the  upper  region  of  the  scapula  is  reached.  The  sepa- 
ration of  the  skin  from  the  subjacent  parts  may  require  at 
certain  points,  like  the  olecranon  or  carpus,  the  aid  of  the 
chisel  or  knife  to  divide  firm  bands  of  connective  tissue. 
This  separation  of  the  skin  from  the  subjacent  parts  has  re- 
moved the  chief  source  of  resistance  to  the  tearing  of  the 
limb  away  from  the  body.  The  next  most  important  obstacle 
is  the  pectoral  muscles  which  should  be  torn  asunder  by 
separating  them  into  small  bundles  and  tearing  them  through 
with  the  fingers  between  the  sternum  and  limb,  or  the  pro- 
cess may  be  aided  by  incision  with  a  knife  or  with  the  chisel. 
When  these  are  well  divided  the  remaining  impediments  to 
tearing  the  shoulder  away  consists  largely  of  the  trapezius 
and  rhomboldeus  muscles  at  the  top,  thelatissimus  dorsi  be- 
hind and  the  great  serratus  and  the  angularis  scapula  which 


HUMERO-RADIAL  AMPUTATION.  187 

only  come  into  action  when  the  shoulder  is  nearly  severed. 
It  is  only  necessary  then  to  separate  the  skin  from  the  limb 
and  divide  the  pectoral  muscles  in  order  to  readily  draw  the 
limb  away  by  traction.  Divide  the  skin  now  around  the 
pastern  and  have  two  or  three  assistants  exert  traction  upon 
the  limb  while  the  operator  places  his  hand  against  the 
sternum  and  pushes  in  the  opposite  direction.  The  impact 
upon  the  maternal  organs  due  to  the  traction  may  be  re- 
duced to  almost  any  desired  degree  by  applying  a  repelling 
force  to  the  sternum  of  the  fetus  so  that  the  impact  upon 
the  maternal  organs  equals  the  difference  between  the  trac- 
tion applied  upon  the  cord  and  the  repulsion  applied  to  the 
fetal  sternum.  If  traction  does  not  bring  the  limb  away 
promptly  the  operator  should  attempt  to  extend  the  division 
of  the  muscles  attaching  the  limb  to  the  thorax  while  moder- 
ate traction  upon  the  limb  is  continued.  Further  diminution 
of  the  size  of  the  fetus  may  now  be  had  by  removal  of  the 
other  limb  in  the  same  way  which  is  especially  desirable  in 
the  transverse  presentation  of  all  four  limbs  in  the  passages 
or  we  may  reduce  the  size  of  the  trunk  by  evisceration  as 
described  under  53. 

This  diminution  suffices  to  permit  the  remnant  of  the 
fetus  to  be  withdrawn  with  the  head  deviated  to  the  side, 
the  total  resistance  being  no  greater  than  had  the  head  and 
neck  presented  normally.  This  diminution  also  makes  the 
foetal  body  very  flaccid,  rendering  it  easy  of  repulsion  and 
simplifies  the  correction  of  deviations  of  any  parts. 


48.     AMPUTATION  AT  HUMERO-RADIAL  ARTICULATION. 

Object.  Amputation  at  this  point  is  rarely  desirable,  but 
may  at  times  be  necessary  in  the  mare  in  order  to  remove 
an  anterior  limb  when  it  is  impossible,  on  account  of  the 
position  to  reach  the  shoulder. 

Technic      Attach    a    cord   to  the  pastern    and  have  an 


1 88  DETR  UNO  A  TION. 

assistant  render  the  leg  tense  by  exerting  moderate  traction, 
as  in  the  preceding.  Introduce  the  hand  armed  with  the 
embryotomy  knife,  carefully  concealed  in  the  palm,  and 
girdle  the  skin  around  the  articulation.  Passing  above  the 
head  of  the  olecranon  on  the  posterior  side,  divide  the 
attachment  of  the  anconean  group  of  muscles  with  the 
knife  by  cutting  from  behind  forward.  Then  divide 
transversely,  as  far  as  possible,  the  muscles  and  ligaments 
passing  over  the  articulation.  Rotate  the  limb  forcibly  on 
its  long  axis  while  strong  traction  is  maintained,  and  rup- 
ture the  principal  ligaments  until  the  limb  is  completely 
detached  and  comes  away.  In  cases  of  limited  room  it  may 
sometimes  be  easier  to  detach  the  skin  of  the  limb  from  the 
pastern  up  to  the  articulation,  as  in  the  preceding  chapter, 
rather  than  to  girdle  the  skin  at  the  articulation. 


49.     DETRUNCATION. 
PI.ATE  XXX. 

Object.  In  case  a  fetus  in  the  anterior  presentation  and 
dorso-sacral  position  has  one  or  both  posterior  limbs  devi- 
ated forward  and  the  feet  engaged  in  or  against  the  pubis, 
it  is  necessary,  or  at  least  advisable  in  the  mare,  that  the 
trunk  of  the  fetus  be  divided  in  order  to  bring  about  delivery 
without  serious  or  fatal  injury  to  the  mother. 

Technic.  Secure  the  two  hind  feet  by  means  of  cords, 
if  possible,  prior  to  other  manipulations.  Apply  cords  to 
the  two  anterior  limbs  and  the  head,  have  one  or  two  assist- 
ants draw  the  anterior  part  of  the  fetus  as  far  out  as  is  prac- 
ticable and  safe,  and  then  girdle  the  foetal  body  immediately 
against  the  maternal  vulva  by  making  an  incision  through 
the  skin  and  skin  muscle.  If  practicable  it  is  best  at  this 
point  to  remove  one  shoulder  subcutaneously,  47,  and  fol- 
low with  evisceration,  53,  in  order  to  give  greater  operative 
room  and  increased  mobility  of  the  foetus.  Insinuate  the 


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192        DESTRUCTION  OF  THE  PELVIC  GIRDLE. 

hand  between  the  skin  and  the  deeper  structures  and  forcibly 
separate  it  from  the  foetal  body  backward  until  the  last  rib 
is  passed,  as  shown  at  the  curved  line  on  the  posterior  border 
of  the  last  foetal  rib  in  Plate  XXX.  Force  the  finger 
tips  through  the  abdominal  wall  behind  the  last  rib  and 
passing,  along  the  entire  border  of  each  posterior  rib,  separate 
the  abdominal  walls  from  the  ribs  and  sternum.  After  the 
abdominal  muscles  have  been  detached  from  the  posterior 
ribs  and  sternum,  and  the  foetus  has  been  eviscerated,  rotate 
the  thorax  upon  its  long  axis  which  will  cause  a  division  of 
the  vertebral  column  near  the  dorso-lumbar  articulation  and 
the  anterior  portion  of  the  foetus  falls  away.  Secure  the 
two  posterior  feet  with  cords,  unless  this  has  already  been 
done,  spread  the  detached  skin  which  has  been  pushed  back 
from  the  thorax,  carefully  over  the  amputation  stump  of  the 
lumbar  vertebrae,  repel  these  by  means  of  the  hand  while 
an  assistant  draws  upon  the  cords  attached  to  the  feet,  push 
the  remnant  of  the  foetal  trunk  into  the  uterus  and  advance 
the  feet  along  the  genital  passages,  thus  converting  the 
remnant  into  a  posterior  presentation.  Ordinarily  this 
would  result  in  a  lumbo-pubic,  which  should  be  converted 
into  the  lumbo-sacral  position  when  its  extraction  can  be 
readily  brought  about. 


50.     DESTRUCTION  OF  THE  PELVIC  GIRDLE  IN  THE 
ANTERIOR  PRESENTATION. 

PLATE  XXXI. 

Object.  In  somewhat  rare  instances  perhaps  more  fre- 
quently in  the  cow  the  pelves  of  the  mother  and  foetus  be- 
come interlocked,  the  antero-external  angle  of  the  foetal 
ilium  I',  becoming  locked  with  the  shaft  of  the  maternal 
ilium  I  at  C  in  such  a  manner  that  any  safe  degree  of  trac- 
tion fails  to  dislodge  it. 

Technic.  Remove  one  anterior  limb  subcutaneously,  47, 
and  eviscerate,  53,  through  an  opening  made  by  the  removal 


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196    AMPUTATION  OF  THE  LIMBS  AT  THE  TARSUS. 

of  two  or  three  of  the  exposed  ribs.  Introduce  the  chisel 
through  this  opening  and  carry  it  back  with  the  hand, 
placing  it  against  the  shaft  of  the  fetal  ilium,  I',  have  an 
assistant  drive  it  through  the  shaft  from  before  to  behind 
and  then  withdrawing  the  chisel  replace  it  against  the  pubic 
brim  either  at  the  symphysis  pubis  or  opposite  the  foramen 
ovale,  and  drive  it  through  the  pubis  and  ischium  at  either  of 
these  points.  The  coxo-femoral  articulation  is  thus  detached 
and  isolated  so  that  the  entire  limb  may  drop  backward 
beyond  its  fellow,  the  remnant  of  the  severed  ilium,  I',  can 
drop  downward  or  move  in  any  direction  and  the  entire  pel- 
vis thus  loses  its  rigidity  and  undergoes  great  diminution  in 
size  so  that  it  can  readily  be  withdrawn. 


51.     AMPUTATION  OF  THE  LIMBS  AT  THE  TARSUS. 
PLATE  XXXII. 

Object.  It  occasionally  happens  in  the  mare,  far  more 
rarely  in  the  cow  in  the  posterior  presentation  with  the  hind 
limbs  retained  at  the  hock  that  owing  to  the  unusual  size  of 
the  fetus  or  its  having  been  dead  for  some  time,  dry  and 
emphysematous,  that  the  deviation  can  not  be  overcome  or 
its  correction  would  entail  an  unnecessary  amount  of  labor. 
In  these  cases  it  is  frequently  easier  for  the  obstetrist  and 
safer  for  the  mother  to  amputate  the  limb  at  the  tarsus. 

Technic.  Pass  a  cord  around  the  leg  above  the  tarsus 
as  indicated  in  Plate  XXXII  and  have  an  assistant  hold  the 
leg  steady  by  gentle  traction.  Introduce  the  chisel  carefully 
guarded  in  the  palm  of  the  hand ,  and  place  it  against  the  lower 
part  of  the  tarsus  as  shown  between  TT.  The  chisel  should 
be  placed  as  nearly  perpendicular  as  possible  to  the  long  axis 
of  the  metatarsus.  The  proper  direction  of  the  chisel  may  at 
times  be  greatly  favored  by  placing  the  cord  upon  the  meta- 


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200  INTRA-PEL  VIC  AMPUTA  TION. 

tarsus  instead  of  the  leg  thus  forcing  the  tarsus  toward  the 
sacrum  of  the  mother  and  tending  to  throw  the  metatarsus 
straight  across  the  pelvic  cavity.  When  the  foetus  is  in  the 
lumbo-sacral  position  and  it  is  desired  to  amputate  the  left  limb 
the  chisel  should  be  held  in  the  palm  of  the  left  hand  with 
the  back  of  the  hand  against  the  vaginal  walls  and  the 
chisel  carefully  guarded  and  guided  during  the  entire 
operation.  Do  not  drive  the  chisel  entirely  through  the 
hock  without  removal  as  it  may  become  caught  and  clamped 
between  the  divided  bones,  but  drive  for  a  few  inches  along 
the  lateral  side  being  sure  that  the  skin  on  that  side  is 
severed  along  with  the  bone,  then  loosen  the  chisel  by  rota- 
tion and  lateral  motion  and  drive  somewhat  deeper  into  the 
tarsus  until  it  is  completely  severed.  Withdraw  the  severed 
metatarsus  and  remove  any  dangerous  spicules  of  bone  re- 
maining on  the  stump  and  see  that  the  latter  is  safely  se- 
cured by  a  cord  passing  around  the  leg  above  the  os  calcis. 
Repeat  the  operation  on  the  other  hock  in  a  similar  manner 
using  the  right  hand  to  guide  the  chisel.  Extend  the  two 
limbs  into  the  passages  by  traction  and  effect  a  posterior 
deliver)7. 


52.     INTRA-PELVIC    AMPUTATION  OF  THE    POSTERIOR 

LIMBS,  BREECH    PRESENTATION. 

PIRATES  XXXIII  AND  XXXIV. 

Uses.  The  overcoming  of  dystocia  due  to  a  posterior 
presentation  with  the  hind  limbs  completely  retained  in  the 
uterus,  the  so-called  breech  presentation,  in  cases  where  the 
deviation  can  not  be  readily  corrected. 

Technic.  Introduce  one  hand  armed  with  the  embry- 
otomy  knife  through  the  maternal  passages  until  the  peri- 
iiaeum  of  the  fetus  is  reached  and  make  a  free  incision 
through  that  region  involving  the  anus  in  the  male  fetus 
and  the  anus  and  vulva  in  the  female  and  enlarge  the 


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204  INTRA-PEL  VIC  AMPUTA  TION. 

incision  sufficiently  to  admit  the  operator's  hand  into  the 
fetal  pelvis.  Locate  the  great  sciatic  ligament  and  inserting 
the  knife  at  the  shaft  of  the  ilium  divide  the  former  back- 
ward to  the  perinaeum  allowing  the  pelvic  cavity  to  dilate 
freely  and  giving  ample  operating  room.  If  the  pelvis  of  the 
fetus  is  too  small  to  admit  the  hand  of  the  operator  at  all  be- 
fore severing  the  sciatic  ligament  this  may  be  accomplished 
by  cautiously  cutting  from  behind  forward  with  Colin 's 
scalpel  or  with  the  chisel.  When  this  has  been  severed  and 
sufficient  operating  room  attained  carry  the  chisel  with  one 
hand  and  plctce  it  against  the  shaft  of  the  ilium  as  shown 
between  I'  I'  in  Plate  XXXIII  as  nearly  perpendicular  to 
the  long  axis  of  the  shaft  as  possible  and  keeping  the  hand 
in  touch  with  the  chisel  blade  have  an  assistant  drive  it 
through  the  bone  until  it  and  its  periosteum  are  completely 
severed.  Disengage  the  chisel  and  then  place  it  against  the 
symphysis  pubis  or  against  theischium  opposite  the  foramen 
ovale  and  drive  it  through  the  ischium  and  pubis  at  this 
point.  Using  the  chisel  as  a  lever,  separate  the  isolated  por- 
tion of  the  pelvis  as  completely  as  practicable  from  the  sur- 
rounding tissues,  and  with  the  ringers  separate  the  muscles 
from  the  detached  pelvic  bone  for  a  short  distance  on 
either  side  from  the  severed  ends.  Carry  a  cord  in  and 
pass  the  loop  over  the  ends  of  the  severed  section  and 
tightening  it  secure  the  isolated  portion  of  the  pelvis  and 
have  one  or  more  assistants  exert  traction  upon  the  cord 
as  indicated  in  Plate  XXXIV.  The  chief  obstacle  to  the 
withdrawal  of  the  limb  is  the  great  glutens  muscle  which 
should  be  sought  for,  identified  and  torn  through  with  the 
ringers  at  a  distance  of  5  or  6  cm.  from  its  attachment  to  the 
great  trochanter.  Other  important  points  of  resistance  are 
the  attachment  posteriorly  of  the  skin,  vulva  and  anus  to 
the  ischium  through  the  medium  of  aponeurosis  and  anter- 
iorly, chiefly  on  the  median  line,  the  prepubic  tendon  ;  these 
are  to  be  cut,  if  necessary,  with  the  chisel  or  knife.  Vigor- 


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208  INTRA-PEL  VIC  AM  PUT  A  TfON. 

otis  traction  may  now  be  applied  by  means  of  the  cord,  the 
operator  in  the  meantime  guarding  the  most  advanced  end 
of  the  detached  piece  of  pelvis  with  the  palm  of  his  hand  in 
order  to  prevent  injury  to  the  maternal  organs.  Sometimes 
this  detached  piece  of  the  pelvis  tears  away  from  the  femur 
when  traction  is  applied  and  comes  away  alone.  In  such  a 
case  the  cord  is  to  be  applied  over  the  head  and  trochanter 
of  the  femur  and  traction  again  applied  drawing  the  limb 
away  in  a  reversed  position,  the  skin  being  turned  back  or 
everted  as  the  limb  advances  until  the  region  of  the  hock  is 
reached  where  the  skin  does  not  so  readily  separate  from  the 
limb  and  only  requires  to  be  cut  loose  and  the  limb  allowed 
to  come  away.  During  the  removal  of  the  limb  the  operator 
is  to  constantly  note  the  progress  with  his  hand  and  sever 
by  tearing  or  cutting  any  tendons  or  muscles  which  offer 
special  obstruction  to  the  work.  Repeat  the  operation  upon 
the  opposite  limb  in  the  same  manner  except  that  but  one 
incision  need  be  made  through  the  bone,  that  is,  through  the 
shaft  of  the  ilium.  During  the  entire  work  the  operation  is 
carried  out  subcutaneously  or  rather  intrafoetally  and  the 
maternal  parts  are  amply  guarded  against  injury.  The  size 
of  the  foetal  trunk  may  be  further  reduced  if  desirable,  by 
evisceration,  53,  and  followed  still  further  by  the  introduction 
of  the  chisel  guided  by  the  hand  and  the  ribs,  on  one  or  both 
sides,  severed  one  after  another  until  the  chest  can  completely 
collapse  and  if  need  be  some  of  the  ribs  may  be  removed  and 
one  of  the  anterior  limbs  caught  by  a  cord  around  the  scap- 
ula and  removed  intra-foetally.  The  remnant  of  the  foetus 
is  to  be  extracted  by  means  of  a  cord  fastened  about  the 
lumbar  region  of  the  spine. 


E  VISCERA  TION.  209 


53.     EVISCERATION. 

The  evisceration  of  the  foetus  is  frequently  desirable  in 
obstetric  practice  and  has  a  variety  of  uses.  It  decreases 
the  size  of  the  foetal  trunk  considerably  and  permits  its  more 
ready  passage  through  the  genital  canal,  as  in  the  anterior 
presentation  ;  with  lateral  deviation  of  the  head  it  renders  the 
foetal  trunk  flaccid  through  the  removal  of  the  viscera  sup- 
porting the  body  walls  and  permits  the  body  remnant  to  be 
bent  or  moved  more  readily  for  the  correction  of  any  devia- 
tions present  ;  it  permits  freedom  of  intra-fcetal  operations 
directed  against  other  parts,  as  for  detruncation,  or  for  the 
destruction  of  the  pelvic  girdle  in  the  anterior  presentation. 

Technic.  Evisceration  may  be  variously  performed,  but 
is  generally  demanded  in  either  the  anterior  or  posterior 
presentation  and  a  description  of  these  will  suffice. 

In  the  anterior  presentation,  unless  the  foetus  is  far  ad- 
vanced through  the  vulva,  evisceration  is  best  performed  by 
the  removal  of  one  or  more  of  the  anterior  ribs.  The  ribs 
are  generall}'  best  reached  by  the  removal  of  the  shoulder, 
as  already  described  under  subcutaneous  amputation  of  the 
anterior  limbs,  47.  When  these  have  been  laid  bare  in  the 
manner  described  the  operator  can  thrust  the  finger  tips 
through  the  intercostal  muscles  in  the  first  intercostal  space 
and  enlarge  the  opening  thus  made  by  tearing  through  the 
muscles  upwards  to  the  spinal  column  and  downwards  to  the 
sternum  ;  then  grasping  the  posterior  border  of  the  rib  near 
its  middle,  fracture  it  by  means  of  a  sudden  and  vigorous 
pull.  The  fractured  ends  may  then  be  grasped  and  pulled,* 
broken  or  twisted  off.  The  chisel  may  be  brought  into  use 
if  required  in  order  to  divide  the  rib,  the  hand  of  the  opera- 
tor constantly  guiding  and  guarding  the  chisel  blade.  The 
operation  is  then  to  be  repeated  if  required,  upon  the  second 
and  third  ribs  in  the  same  manner  until  an  opening  into  the 
14 


210  E  VISCERA  770 N. 

chest  is  secured  ample  in  size  for  the  introduction  of  the 
operator's  hand. 

Force  one  hand  through  the  opening  and  tear  the  medi- 
astinin  above  and  below  from  the  thoracic  walls,  and  then 
grasp  either  the  trachea  at  its  bifurcation  or  the  heart  and 
tear  them  away.  The  heart,  which  constitutes  the  greater 
bulk  of  the  thoracic  viscera,  is  best  grasped  in  the  palm  of 
the  hand,  with  the  ringers  engaging  the  aorta  and  pulmo- 
nary arteries.  When  the  thoracic  viscera  have  been  with- 
drawn, thrust  the  fingers  through  the  diaphragm  and 
locating  the  liver,  isolate  the  area  of  the  diaphragm  to  which 
it  is  attached,  and  engaging  both  with  the  ringers  remove 
the  two  together.  The  liver  constitutes,  in  a  normal  foetus, 
the  chief  intra-abdomiual  mass,  occupving  more  space  than 
all  other  organs  combined.  After  the  liver  has  been  re- 
moved the  intestinal  tube,  with  its  contents,  are  withdrawn 
without  difficulty,  as  its  attachments  are  feeble.  The  kid- 
neys may  also  be  removed. 

Evisceration  in  the  posterior  presentation  is  preferably 
performed  through  the  pelvis,  generally  in  connection  with 
52.  It  ma}'  be  performed  without  destruction  of  the  pelvic 
girdle  by  making  an  incision  through  the  perineal  region 
and  then  severing  the  sacro-sciatic  ligament  as  directed 
under  52.  When  admission  has  been  gained  to  the  abdom- 
inal cavity  introduce  the  hand  and  withdraw  the  alimentary 
tube,  then  rupture  the  diaphragm  about  the  liver  and  tear 
away  the  latter  organ  in  the  same  manner  as  in  the  anterior 
presentation.  The  liver  is  so  friable  that  it  cannot  well  be 
torn  away  by  grasping  the  organ  itself,  but  comes  away  en- 
tire with  the  central  part  of  the  diaphragm. 

Remove  the  heart  and  lungs  as  above  directed. 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 


This  book  is  aue  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 
Renewed  books  are  subject  to  immediate  recall. 


MAK  3 

1  1961 

24V*IGC 

JAN  1  0  1963 

jt4'biBB        ' 

APR 

13  19 

n 

APR  13 

1971 

5 

JUN-9 

1971 

MAI    27 

1971     5 

LD  21-50m-6,'59 
(A2845slO)476 


General  Library 

University  of  California 

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